Incidence and management of complications after neoadjuvant chemotherapy followed by extrapleural pneumonectomy for malignant pleural mesothelioma.

Objective: To investigate the incidence and management of postoperative complications after neoadjuvant chemotherapy followed by extrapleural pneumonectomy for malignant pleural mesothelioma.
Methods: Patients with histologically proven mesothelioma of clinical stages T1-3, N0-2, M0 and considered to be completely resectable received neoadjuvant chemotherapy (cisplatin+gemcitabine or cisplatin+pemetrexed) followed by extrapleural pneumonectomy and postoperative radiotherapy. The incidence and management of postoperative complications in general and of bronchopleural fistula and postpneumonectomy-empyema in particular were analyzed. Univariate analysis was performed to identify prognostic factors [sex, age, side of operation, weight loss, smoking, chemotherapy, EORTC-score (European Organization for Research and Treatment of Cancer-classification) and duration of operation].
Results: Between 1st May 1999 and 15th August 2005, 63 patients underwent complete extrapleural pneumonectomy after neoadjuvant chemotherapy. Postoperative complications were observed in 39 cases (62%) and 2 patients died within 30 days (3.2%). Postpneumonectomy-empyema occurred in 15.8% of the patients (n=10), six with a bronchopleural fistula on the right side. All empyemas were treated successfully. Five patients developed chylothorax (7.9%) and four patients had complications due to a patch failure: cardiac herniation (n=2), restriction of cardiac output (n=1) or gastric herniation (n=1). Patients with higher EORTC-score presented significantly more postoperative complications (p=0.03). A longer duration of surgery tended to be associated with a higher incidence of postoperative complications, especially of empyemas.
Conclusions: Extrapleural pneumonectomy after neoadjuvant chemotherapy can be performed with mortality rates comparable to standard pneumonectomies. Complications are frequent but can be successfully managed; the EORTC-score seems to be a predictor for postoperative complications.