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Objective: To report on the experience with radical surgery, with emphasis on the long-term outcome, for malignant pleural mesothelioma (MPM) at a single institution., Methods: From our prospective database over a 17-year period, we reviewed 83 consecutive patients undergoing radical surgery for MPM in a multimodality programme. The long-term overall survival was analysed using the Kaplan-Meier method., Results: A total of 83 patients (65 males, median age: 60 years) underwent an extra-pleural pneumonectomy (EPP) with a curative intent. Epitheliod MPM was the most frequent (82%) cause. A right-sided disease was present in half of the cases (n=42). The International Mesothelioma Interest Group (IMIG) stage of the disease was 2 in 36%, 3 in 45% and 4 in 9% of the cases. Preoperative chemotherapy consisting of a doublet cisplatin-pemetrexed (mean of three cycles) was offered to 10 patients (12%). Postoperative therapies, either chemotherapy or radiotherapy, were given in 25 patients (30%). The 30-day and 90-day mortality rates were 4.8% and 10.8%, respectively. Postoperative complications occurred in 39.8% and were major in 23 patients (27.7%). Re-operation was necessary in 12 cases (14.5%) for one of the following reasons: broncho-pleural fistula (n=4), bleeding (n=3), diaphragmatic patch rupture (n=3), oesophago-pleural fistula (n=1) and empyaema (n=1). The mean hospital stay was 43 days. The median survival was 14.5 months, while the overall 1-, 2- and 5-year survival rates were 62.4%, 32.2% and 14.3%, respectively., Conclusions: These results concur with the published data of the most experienced centre with regards to the mortality and morbidity after EPP for MPM. In line with the biggest series reported in the past, the observed 5-year survival rate of almost 15% is disappointing.

Objective: Analysis of a single institution experience with completion pneumonectomy., Methods: From 1989 to 2002, 55 consecutive cancer patients received completion pneumonectomy (mean age 62 years; 25-79). Indications were bronchogenic carcinoma in 38 patients (4 first cancers, 8 recurrent cancers, 26 second cancers), lung metastases in three (one each from breast cancer, colorectal neoplasm and lung cancer), lung sarcoma in one, and miscellaneous non-malignant conditions in 13 patients having been surgically treated for a non-small cell lung cancer previously (bronchopleural fistula in 4, radionecrosis in 3, aspergilloma in 2, pachypleura in 1, massive hemoptysis in 1 and pneumonia in 2). Before completion pneumonectomy, 50 patients had had a lobectomy, three a bilobectomy, and two lesser resections. The mean interval between the two procedures was 51 months for the whole group (1-469), 60 months for lung cancer (12-469), 43 months for pulmonary metastases (21-59) and 29 months for non-malignant disorders (1-126)., Results: There were 35 right (64%) and 20 left (36%) resections. The surgical approaches were a posterolateral thoracotomy in 50 cases (91%) and a lateral thoracotomy in five cases (9%). Intrapericardial route was used in 49 patients (89%). Five patients had an extended resection (2 chest wall, 1 diaphragm, 1 subclavian artery and 1 superior vena cava). Operative mortality was 16.4% (n=9): 11.9% for malignant disease (n=5) and 30.8% for benign disease (n=4) Operative mortality was 20% for right completion pneumonectomies (n=7) and 10% for left-sided procedures (n=2) Twenty-three patients (42%) experienced non-fatal major complications. Actuarial 3- and 5-year survival rates from the time of completion pneumonectomy were 48.4 and 35.2% for the entire group. Three- and five-year survival for patients with bronchogenic carcinoma were 56.9 and 43.4%, respectively., Conclusions: These results suggest that completion pneumonectomy in the setting of lung malignancies can be done with an operative risk similar to the one reported for standard pneumonectomy. In contrast, in cancer patients, completion pneumonectomy for inflammatory disorders is a very high-risk procedure.

Background: The management of non-small cell carcinomas of the lung involving the superior sulcus remains controversial. The goal of this retrospective study was to evaluate the role of surgery, radiotherapy, and chemotherapy for the treatment of superior sulcus tumors, to define the best surgical approach for radical resection, and to identify factors influencing long-term survival., Methods: Between 1983 and 1999, 139 patients underwent surgical resection of superior sulcus tumors in seven thoracic surgery centers. According to the classification of the American Joint Committee, 51.1% of cancers were stage IIB, 13.7% stage IIIA, 32.4% stage IIIB, and 2.9% stage IV., Results: The resections were performed with 74.1% using the posterior approach and 25.9% using an anterior approach. A lobectomy was accomplished in 69.8% of the cases and a wedge resection in 22.3%. Resection of a segment of vertebrae or subclavian artery was performed, respectively, in 19.4% and 18% of the cases. Resection was complete in 81.3% of cancers. The overall 5-year survival rate was 35%. Preoperative radiotherapy improved 5-year survival for stages IIB-IIIA. Surgical approach, postoperative radiotherapy, or chemotherapy did not change survival., Conclusions: The optimal treatment for superior sulcus tumors is complete surgical resection. The surgical approach (anterior/posterior) did not influence the 5-year survival rate. Preoperative radiotherapy should be recommended to improve outcome of patients with a superior sulcus tumor.

Objective: No guidelines detailing recommendations for the selection and treatment of patients with synchronous multiple primary lung cancer have been published. We report on a single-institution experience with synchronous multiple primary lung cancer, with emphasis on long-term survival. Methods: We performed a retrospective study of 125 consecutive patients with synchronous multiple primary lung cancer who underwent operation between 1985 and 2006. Various treatment strategies were applied, including perioperative therapy. Potential prognosticators were submitted to univariate and multivariate analyses. Results: Tumors were bilateral (n = 34) or ipsilateral (n = 91). Optimal surgical treatment (complete anatomic resection with radical lymphadenectomy) was possible in 65.6% of the cases. pN0 disease was present in 32.3% of the patients; 30-day and 90-day mortality rates were 4.5% and 11%, respectively. Two- and 5-year overall survivals were 61.6% and 34%, respectively, with a median survival of 35 months. On univariate analysis, smoking status, high Charlson index, low forced expiratory volume in 1 second, occurrence of postoperative complications, and performance of a pneumonectomy affected the overall survival adversely. Conversely, bilateral disease, location in the same lobe, and pN0 disease were favorable prognosticators. On multivariate analysis, low forced expiratory volume in 1 second, nonoptimal surgical treatment, and performance of a pneumonectomy were independent predictors of poor long-term survival, whereas female sex, younger age, asymptomatic disease, pN0 status, and performance of an adjuvant treatment affected the survival favorably. Conclusions: Provided there is an appropriate selection process, patients with synchronous multiple primary lung cancer are expected to benefit from surgery. Optimal surgery should be performed, but pneumonectomy should be avoided whenever possible. Adjuvant treatment is suggested to provide an added survival advantage. [Copyright &y& Elsevier]