Patients with peritoneal mesothelioma present with abdominal distension and clinical syndrome of debilitating ascites. Cytology of the peritoneal fluid obtained by laparocentesis often does not result in a diagnosis. Laparoscopy with biopsy of peritoneal nodules is a valuable method by which a diagnosis is established. However, laparscopy can greatly complicate the management of peritoneal mesothelioma by facilitating tumor dissemination ("tracking") to port sites. The patient presented was treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy. Although palliation of intra-abdominal tumor and ascites was achieved, port sites-disease required extensive resection of the abdominal wall. Experience with this patient suggests that if a malignant source of ascites is suspected and a diagnosis is not obtained by paracentesis, laparoscopy should be used to establish a diagnosis. However, trocars should only be placed along the midline of the abdominal wall so that port sites can be excised at the time of cytoreductive surgery. This diagnostic strategy is applicable to the majority of patients undergoing laparoscopy when there is known or suspected intraabdominal malignancy. Muenstere, et ., International Surgery, 92(3):240-3, July- September 1997.SURGERY
MALIGNANT PERITONEAL MESOTHELIOMA: PITFALLS OF DIAGNOSTIC LAPAROSCOPY.
PLEURECTOMY/DECORTICATION EXCELLENT RELIEF FOR MALIGNANT PLEURAL MESOTHELIOMA. Surgery can only offer palliation in an attempt to slow the progression of malignant pleural mesothelioma (MPM). This study assessed the effectiveness and safety of pleurectomy/decortication in establishing a tissue diagnosis and controlling pleural fluid accumulation and symptoms in patients with MPM. METHODS: Pleurectomy results in 100 patients with MPM over a 19 year period were reviewed. Major symptoms were chest pain, cough and dyspnea, and radiographic findings included pleural mass, pleural fluid and constriction of involved hemithorax. RESULTS: Approximately two thirds of the patients underwent surgery prior to tissue diagnosis. Eighty-nine patients had stage I and stage II disease, 8 and 81%, respectively. The patients underwent subtotal (44%) or total pleurectomy (56%). The surgical mortality rate was 1% and the morbidity rate was 22%. Morbidity included prolonged air leak, empyema (accumulation of pus in the body cavity), reaccumulation of pleural fluid and wound infection. Palliative results included dyspnea (labored breathing) and cough relief in all patients, chest relief in 60 (85%) and pleural fluid control in 52 (96%) patients. Median survival was 17 months in MPM patients. CONCLUSIONS: Pleurectomy/decortication safely provides both tissue diagnosis and effective control of pleural effusion and symptoms and therefore excellent palliation in patients with MPM. Soysal, et al., European Journal of Cardio-Thoracic Surgery, 11(2):210-3, February 1997.
TUMOR SIZE AND PLATELET COUNT PROGNOSTIC INDICATORS FOR DEBULKING MALIGNANT PLEURAL MESOTHELIOMA. BACKGROUND: Morbidity and mortality, sites of recurrence, and possible prognostic factors in 95 (78 male, 17 female) patients with MPM on phase I-III trials since 1990 were analyzed. A debulking resection (excision) to a requisite, residual tumor thickness of at least 5 mm was required for inclusion in the study. METHODS: Preoperative tumor volumes were determined by three-dimensional reconstruction of chest computerized tomograms. Pleurectomy or extrapleural pneumonectomy (EPP) was performed. Seventeen patients could not be debulked. Preoperative EPP platelet counts (404,000) and mean tumor volume (491 cubic centimeters) were greater than that seen for pleurectomy (344,000, 114 cubic centimeters). RESULTS: Median survival for all patients was 11.2 months, with that for pleurectomy 14.5 months, that for EPP 9.4 months, and that for unresectable patients 5.0 months. Arrhythmia (15%) was the most common complication, and there were two deaths related to surgery (2%). Tumor volume of greater than 100 milliliter, biphasic histology, male sex, and elevated platelet count were associated with decreased survival. Both EPP and pleurectomy had equivalent recurrence rates (27 of 39 [69%] and 31 of 39 [79%], respectively); however, 17 of 27 EPP recurrences as opposed to 28 of 31 pleurectomy recurrences were locoregional (to the original tumor site). CONCLUSIONS: Debulking resections for MPM can be performed with low operative mortality. Size and platelet count are important preoperative prognostic parameters for MPM. Patients with poor prognostic indicators should probably enter nonsurgical, innovative trials where toxicity or response to therapy can be evaluated. Pass, et al., Annals of Surgical Oncology, 4(3):215-22, April through May 1997.
LONG SURVIVAL AFTER EXTRAPLEURAL PNEUMONECTOMY FOR PLEURAL MALIGNANT MESOTHELIOMA WITH METASTASIS TO INFRADIAPHRAGMATIC LYMPH NODE. A woman who at the age of 47 years underwent extrapleural pneumonectomy for malignant pleural mesothelioma with metastasis to an infradiaphragmatic lymph node is alive and well 63 months later. Because such metastasis is readily caused by lymphatic tumour-cell permeation form the diaphragm and parietal pleura, the infradiaphragmatic nodes should be dissected at extrapleural pneumonectomy for malignant pleural mesothelioma. Nomori, et al., Scandinavian Cardiovascular Journal, 31(4):237-9, 1997.