Extrapleural Pneumonectomy for Pleural Malignancies Andrea S. Wolf, MD, Raja M. Flores, MD* KEYWORDS Extrapleural pneumonectomy Nonsmall cell lung cancer Malignant pleural effusion Pleural carcinomatosis
KEY POINTS Extrapleural pneumonectomy (EPP) is a radical procedure involving en bloc resection of the lung with parietal and visceral pleurae, and usually ipsilateral diaphragm and pericardium. EPP was initially described in the treatment of refractory tuberculosis and is currently more commonly employed in the treatment of malignant pleural mesothelioma. Several centers have successfully performed EPP in the context of treatment of pleural dissemination of nonmesothelioma malignancies, including thymoma and nonsmall cell lung cancer (NSCLC). Patients with stage IV NSCLC caused by malignant pleural effusion without mediastinal nodal or distant metastases may be considered for EPP following induction chemotherapy.
Extrapleural pneumonectomy (EPP) is a radical procedure involving resection of the lung, visceral and parietal pleura, and, generally, the ipsilateral diaphragm and pericardium, with reconstruction of the latter two. Historically, this procedure has been employed to treat infection (tuberculosis) and diffuse malignant pleural mesothelioma. EPP may also have a role in select cases in the treatment of pleural dissemination of nonmesothelioma malignancies, such as nonsmall cell lung cancer (NSCLC), thymoma, and other tumors.
HISTORY Irving Sarot was the first to describe the technique of EPP in the mid-20th century, as performed at the Mount Sinai Hospital in New York City.1 He reported individual cases and results
for 23 patients whose tuberculous infection of the chest was either not amenable to or had failed other treatments, such as thoracoplasty or collapse therapy. Sarot concluded that the extrapleural dissection “extend (ed) the range of excisional surgeries,” enabling safe resection even in the case of empyema and total pleural symphysis. In 1976, Butchart and colleagues2 at the University of New Castle were the first to report employing EPP to treat patients with malignant pleural mesothelioma. Operative mortality in Butchart’s series was 31% and considered prohibitive, leading many physicians to question the role of EPP in treating patients with pleural mesothelioma. Nevertheless, Butchart concluded that if the complication and perioperative death rates could be reduced, the procedure could be indicated for certain types of disease. He emphasized that appropriate preoperative cardiopulmonary evaluation and careful intra- and
Disclosure Statement: The authors have no relevant financial disclosures to disclose. Department of Thoracic Surgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1023, New York, NY 10029, USA * Corresponding author. E-mail address: [email protected] Thorac Surg Clin 24 (2014) 471–475 http://dx.doi.org/10.1016/j.thorsurg.2014.07.014 1547-4127/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
thoracic.theclinics.com
INTRODUCTION
472
Wolf & Flores postoperative management were critical to reducing operative morbidity and mortality for EPP. In the two decades that followed Butchart’s series, improvements in preoperative patient selection, intraoperative technique and anesthesia, and postoperative recognition and management of complications3 reduced the mortality of EPP to rates under 4%.4 Modern series describing results of EPP in pleural mesothelioma patients report postoperative mortality of 2.2% to 7%.5–9 Currently, EPP and the lung-sparing alternative, extended pleurectomy/decortication, are considered by many to have a critical role in the multimodality treatment of malignant pleural mesothelioma.10
PLEURAL DISSEMINATION OF MALIGNANCY Whereas malignant pleural mesothelioma represents a primary tumor of the pleura, many malignancies, including lung, colon, breast, thymoma, sarcoma, and others, metastasize to the pleura. Reduced mortality and morbidity of the modern EPP technique have led surgeons to explore the role of this procedure in the management of pleural dissemination of other tumors (Table 1). Flores and colleagues11 reported a small series of 4 pediatric patients who underwent EPP, only 1 of whom had pleural mesothelioma.
Thymoma Thymoma in particular has a tendency toward pleural spread, and several groups have described their experience with extended resection, including EPP, for locally advanced disease.12 Wright described the Massachusetts General Hospital experience with 5 patients who underwent EPP for stage IVa thymoma.13 There were no postoperative deaths and one major complication (tamponade requiring removal of the pericardial patch); 5-year survival was 53% (95% confidence interval [CI] 25%–75%). In another retrospective study, Huang and colleagues14 reported Memorial Sloan-Kettering Cancer Center’s series of 18 patients undergoing extended resection for stage IVa thymoma following induction chemotherapy, including 4 patients who underwent EPP and adjuvant radiation. There were no postoperative deaths, and 5-year survival for the group (including other types of extended resection) was 78%. Ishikawa and colleagues15 at the Tochigi Cancer Center published another report of 11 patients undergoing similar extended resection for stage IVa or IVb thymoma, with 4 patients undergoing EPP. There were no postoperative deaths, and 5-year survival was 75%.
Sarcoma Pleural dissemination of sarcoma is difficult to treat in general and with surgery in particular. There are only rare reports in the literature describing EPP for sarcoma. In a two-patient series (1 chondrosarcoma and 1 hemangiopericytoma), 1 patient died of disease 2 years after EPP, and the other was alive 4.5 years after EPP (and 1 year following limited chest wall resection for recurrence).16 In a more comprehensive series of patients undergoing EPP for pleural dissemination of various malignancies, Sugarbaker and colleagues17 reported that 10 patients with sarcoma experienced a median survival of 3.7 months. Although we offer EPP in selected healthy sarcoma patients with limited or no alternative therapeutic options, we are less enthusiastic about performing EPP for this disease.
PLEURAL DISSEMINATION OF NONSMALL CELL LUNG CANCER Nonsmall Cell Lung Cancer Staging Like other malignancies, NSCLC may metastasize to the pleura, resulting in malignant pleural effusion. The TNM NSCLC staging system in the Sixth Edition of the American Joint Committee on Cancer (AJCC) described malignant pleural effusion without other metastases as T4M0 or stage IIIb NSCLC,18 with many clinicians referring to this as “wet IIIb” lung cancer to distinguish it from stage IIIb patients with contralateral mediastinal or supraclavicular nodal disease. In the Seventh edition, however, malignant pleural effusion was upstaged to M1 (M1a in contrast to M1b, which represents distant metastases) or stage IV NSCLC.19 The International Association for the Study of Lung Cancer (IASLC) Staging Committee based this change on data suggesting the survival of patients with malignant pleural effusion was similar to that of patients with distant metastases and significantly worse than that of patients with other types of T4 tumors. Five-year survival for the 471 patients with malignant pleural effusion in the IASLC database was 2%, compared with 14% in the 418 patients with other types of T4 tumors (P1 y 1 patient alive as of 39 mo 3/65 (5%) 29/65 (45%) Median survival: including Not reached at 22 mo arrhythmia (thymoma) 3.7 mo (sarcoma) 16.7 mo (NSCLC)
Perioperative Considerations
Postoperative Care
From the anesthesiologist’s standpoint, preparation for surgery includes the placement of routine monitors, lines, and an epidural catheter for perioperative pain control.25 An arterial line is mandated given the likelihood of rapid hemodynamic changes, and large bore intravenous access, including a central line, is recommended. If there is any question as to the possibility of existent pulmonary hypertension, the authors recommend placement of a Swan-Ganz catheter (which must be pulled back prior to division of the pulmonary artery). Central lines should be placed on the operative side to avoid pneumothorax on the side of the ventilated (and postoperatively, only) lung. Lung isolation may be obtained with double-lumen endotracheal tube (preferred) or bronchial blocker, with the latter to be pulled back prior to division of the bronchus. Finally, the authors recommend placement of a nasogastric tube to aid in identifying the esophagus intraoperatively and to decompress the stomach postoperatively. The extrapleural dissection and division of vagal fibers extending to the bronchus often lead to mild postoperative esophageal dysmotility, and nasogastric decompression may prevent lifethreatening aspiration in the early postoperative period in these patients with one remaining lung.
Surgery should be performed at centers in which surgeons, nurses, anesthesiologists, and additional clinicians providing perioperative and postoperative care are experienced with the course of patients undergoing EPP. Early recognition of subtle hemodynamic and/or respiratory changes can preempt life-threatening complications. For example, proper pneumonectomy space management can prevent fatal mediastinal shift.26 Avoiding postoperative death mandates immediate identification of tamponade, cardiac herniation, patch dehiscence, DVT, pulmonary embolus, and other morbidity.3 Finally, careful management of fluid status and pulmonary toilet is also critical to the postoperative care of these patients.
SUMMARY Although originally performed on patients with refractory tuberculosis and malignant pleural mesothelioma, extrapleural pneumonectomy may be used to treat patients with pleural dissemination of other malignancies, including thymoma and NSCLC. Patients who present with stage IV NSCLC caused by malignant pleural effusion may be considered for EPP following induction chemotherapy if they demonstrate no mediastinal
Extrapleural Pneumonectomy for Pleural Malignancies nodal or distant metastases and have adequate cardiopulmonary reserve. EPP for NSCLC should be performed by experienced teams at experienced centers to minimize the morbidity and mortality associated with this radical procedure. Additional prospective studies are needed to better characterize the role of EPP in the multimodality treatment of patients with pleural dissemination of malignancy, including NSCLC.
REFERENCES 1. Sarot IA. Extrapleural pneumonectomy and pleurectomy in pulmonary tuberculosis. Thorax 1949;4: 173–223. 2. Butchart EG, Ashcroft T, Barnsley WC, et al. Pleuropneumonectomy in the management of diffuse malignant mesothelioma of the pleura. Experience with 29 patients. Thorax 1976;31:15–24. 3. Sugarbaker DJ, Jaklitsch MT, Bueno R, et al. Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies. J Thorac Cardiovasc Surg 2004;128:138–46. 4. Sugarbaker DJ, Flores RM, Jaklitsch MT, et al. Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: results in 183 patients. J Thorac Cardiovasc Surg 1999;117:54–63 [discussion: 63–5]. 5. Flores RM, Pass HI, Seshan VE, et al. Extrapleural pneumonectomy versus pleurectomy/decortication in the surgical management of malignant pleural mesothelioma: results in 663 patients. J Thorac Cardiovasc Surg 2008;135:620–6. 6. Wolf AS, Daniel J, Sugarbaker DJ. Surgical techniques for multimodality treatment of malignant pleural mesothelioma: extrapleural pneumonectomy and pleurectomy/decortication. Semin Thorac Cardiovasc Surg 2009;21:132–48. 7. Flores RM. Surgical options in malignant pleural mesothelioma: extrapleural pneumonectomy or pleurectomy/decortication. Semin Thorac Cardiovasc Surg 2009;21:149–53. 8. Sugarbaker DJ, Wolf AS. Surgery for malignant pleural mesothelioma. Expert Rev Respir Med 2010;4:363–72. 9. Cao C, Tian D, Park J, et al. A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma. Lung Cancer 2014;83:240–5. 10. Rusch V, Baldini EH, Bueno R, et al. The role of surgical cytoreduction in the treatment of malignant pleural mesothelioma: meeting summary of the International Mesothelioma Interest Group Congress, September 11-14, 2012, Boston, Mass. J Thorac Cardiovasc Surg 2013;145:909–10. 11. Flores RM, Su W, Lal D, et al. Extrapleural pneumonectomy in children. J Pediatr Surg 2006;41:1738–42.
12. Wright CD. Extended resections for thymic malignancies. J Thorac Oncol 2010;5:S344–7. 13. Wright CD. Pleuropneumonectomy for the treatment of Masaoka stage IVA thymoma. Ann Thorac Surg 2006;82:1234–9. 14. Huang J, Rizk NP, Travis WD, et al. Feasibility of multimodality therapy including extended resections in stage IVA thymoma. J Thorac Cardiovasc Surg 2007;134:1477–83 [discussion: 1483–4]. 15. Ishikawa Y, Matsuguma H, Nakahara R, et al. Multimodality therapy for patients with invasive thymoma disseminated into the pleural cavity: the potential role of extrapleural pneumonectomy. Ann Thorac Surg 2009;88:952–7. 16. Bedini AV, Tavecchio L, Delledonne V. Extrapleural pneumonectomy for sarcomas report of two cases. Tumori 2000;86:422–3. 17. Sugarbaker DJ, Tilleman TR, Swanson SJ, et al. The role of extrapleural pneumonectomy in the management of pleural cancers. J Clin Oncol 2009;27:7577. 18. Greene FL. The American Joint Committee on Cancer: updating the strategies in cancer staging. Bull Am Coll Surg 2002;87:13–5. 19. Rami-Porta R, Crowley JJ, Goldstraw P. The revised TNM staging system for lung cancer. Ann Thorac Cardiovasc Surg 2009;15:4–9. 20. Rami-Porta R, Ball D, Crowley J, et al. The IASLC Lung Cancer Staging Project: proposals for the revision of the T descriptors in the forthcoming (seventh) edition of the TNM classification for lung cancer. J Thorac Oncol 2007;2:593–602. 21. Swanson SJ, Jaklitsch MT, Mentzer SJ, et al. Induction chemotherapy, surgical resection and radiotherapy in patients with malignant pleural effusion, mediastinoscopy negative (stage IIIB) non-small cell lung cancer. American Association for Thoracic Surgery 78th Annual Meeting Abstract Book 1998. Boston, May 3–6, 1998. 22. Ichinose Y, Tsuchiya R, Koike T, et al. Prognosis of resected non-small cell lung cancer patients with carcinomatous pleuritis of minimal disease. Lung Cancer 2001;32:55–60. 23. Suzuki K, Funai K, Shundo Y, et al. Extrapleural pneumonectomy after hyperthermo-chemotherapy for the lung cancer patients with malignant pleural effusion. Kyobu Geka 2004;57:1023–7 [in Japanese]. 24. Yokoi K, Matsuguma H, Anraku M. Extrapleural pneumonectomy for lung cancer with carcinomatous pleuritis. J Thorac Cardiovasc Surg 2002;123:184–5. 25. Ng JM, Hartigan PM. Anesthetic management of patients undergoing extrapleural pneumonectomy for mesothelioma. Curr Opin Anaesthesiol 2008;21:21–7. 26. Wolf AS, Jacobson FL, Tilleman TR, et al. Managing the pneumonectomy space after extrapleural pneumonectomy: postoperative intrathoracic pressure monitoring. Eur J Cardiothorac Surg 2010; 37:770–5.
475
KEY POINTS Extrapleural pneumonectomy (EPP) is a radical procedure involving en bloc resection of the lung with parietal and visceral pleurae, and usually ipsilateral diaphragm and pericardium. EPP was initially described in the treatment of refractory tuberculosis and is currently more commonly employed in the treatment of malignant pleural mesothelioma. Several centers have successfully performed EPP in the context of treatment of pleural dissemination of nonmesothelioma malignancies, including thymoma and nonsmall cell lung cancer (NSCLC). Patients with stage IV NSCLC caused by malignant pleural effusion without mediastinal nodal or distant metastases may be considered for EPP following induction chemotherapy.
Extrapleural pneumonectomy (EPP) is a radical procedure involving resection of the lung, visceral and parietal pleura, and, generally, the ipsilateral diaphragm and pericardium, with reconstruction of the latter two. Historically, this procedure has been employed to treat infection (tuberculosis) and diffuse malignant pleural mesothelioma. EPP may also have a role in select cases in the treatment of pleural dissemination of nonmesothelioma malignancies, such as nonsmall cell lung cancer (NSCLC), thymoma, and other tumors.
HISTORY Irving Sarot was the first to describe the technique of EPP in the mid-20th century, as performed at the Mount Sinai Hospital in New York City.1 He reported individual cases and results
for 23 patients whose tuberculous infection of the chest was either not amenable to or had failed other treatments, such as thoracoplasty or collapse therapy. Sarot concluded that the extrapleural dissection “extend (ed) the range of excisional surgeries,” enabling safe resection even in the case of empyema and total pleural symphysis. In 1976, Butchart and colleagues2 at the University of New Castle were the first to report employing EPP to treat patients with malignant pleural mesothelioma. Operative mortality in Butchart’s series was 31% and considered prohibitive, leading many physicians to question the role of EPP in treating patients with pleural mesothelioma. Nevertheless, Butchart concluded that if the complication and perioperative death rates could be reduced, the procedure could be indicated for certain types of disease. He emphasized that appropriate preoperative cardiopulmonary evaluation and careful intra- and
Disclosure Statement: The authors have no relevant financial disclosures to disclose. Department of Thoracic Surgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1023, New York, NY 10029, USA * Corresponding author. E-mail address: [email protected] Thorac Surg Clin 24 (2014) 471–475 http://dx.doi.org/10.1016/j.thorsurg.2014.07.014 1547-4127/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
thoracic.theclinics.com
INTRODUCTION
472
Wolf & Flores postoperative management were critical to reducing operative morbidity and mortality for EPP. In the two decades that followed Butchart’s series, improvements in preoperative patient selection, intraoperative technique and anesthesia, and postoperative recognition and management of complications3 reduced the mortality of EPP to rates under 4%.4 Modern series describing results of EPP in pleural mesothelioma patients report postoperative mortality of 2.2% to 7%.5–9 Currently, EPP and the lung-sparing alternative, extended pleurectomy/decortication, are considered by many to have a critical role in the multimodality treatment of malignant pleural mesothelioma.10
PLEURAL DISSEMINATION OF MALIGNANCY Whereas malignant pleural mesothelioma represents a primary tumor of the pleura, many malignancies, including lung, colon, breast, thymoma, sarcoma, and others, metastasize to the pleura. Reduced mortality and morbidity of the modern EPP technique have led surgeons to explore the role of this procedure in the management of pleural dissemination of other tumors (Table 1). Flores and colleagues11 reported a small series of 4 pediatric patients who underwent EPP, only 1 of whom had pleural mesothelioma.
Thymoma Thymoma in particular has a tendency toward pleural spread, and several groups have described their experience with extended resection, including EPP, for locally advanced disease.12 Wright described the Massachusetts General Hospital experience with 5 patients who underwent EPP for stage IVa thymoma.13 There were no postoperative deaths and one major complication (tamponade requiring removal of the pericardial patch); 5-year survival was 53% (95% confidence interval [CI] 25%–75%). In another retrospective study, Huang and colleagues14 reported Memorial Sloan-Kettering Cancer Center’s series of 18 patients undergoing extended resection for stage IVa thymoma following induction chemotherapy, including 4 patients who underwent EPP and adjuvant radiation. There were no postoperative deaths, and 5-year survival for the group (including other types of extended resection) was 78%. Ishikawa and colleagues15 at the Tochigi Cancer Center published another report of 11 patients undergoing similar extended resection for stage IVa or IVb thymoma, with 4 patients undergoing EPP. There were no postoperative deaths, and 5-year survival was 75%.
Sarcoma Pleural dissemination of sarcoma is difficult to treat in general and with surgery in particular. There are only rare reports in the literature describing EPP for sarcoma. In a two-patient series (1 chondrosarcoma and 1 hemangiopericytoma), 1 patient died of disease 2 years after EPP, and the other was alive 4.5 years after EPP (and 1 year following limited chest wall resection for recurrence).16 In a more comprehensive series of patients undergoing EPP for pleural dissemination of various malignancies, Sugarbaker and colleagues17 reported that 10 patients with sarcoma experienced a median survival of 3.7 months. Although we offer EPP in selected healthy sarcoma patients with limited or no alternative therapeutic options, we are less enthusiastic about performing EPP for this disease.
PLEURAL DISSEMINATION OF NONSMALL CELL LUNG CANCER Nonsmall Cell Lung Cancer Staging Like other malignancies, NSCLC may metastasize to the pleura, resulting in malignant pleural effusion. The TNM NSCLC staging system in the Sixth Edition of the American Joint Committee on Cancer (AJCC) described malignant pleural effusion without other metastases as T4M0 or stage IIIb NSCLC,18 with many clinicians referring to this as “wet IIIb” lung cancer to distinguish it from stage IIIb patients with contralateral mediastinal or supraclavicular nodal disease. In the Seventh edition, however, malignant pleural effusion was upstaged to M1 (M1a in contrast to M1b, which represents distant metastases) or stage IV NSCLC.19 The International Association for the Study of Lung Cancer (IASLC) Staging Committee based this change on data suggesting the survival of patients with malignant pleural effusion was similar to that of patients with distant metastases and significantly worse than that of patients with other types of T4 tumors. Five-year survival for the 471 patients with malignant pleural effusion in the IASLC database was 2%, compared with 14% in the 418 patients with other types of T4 tumors (P1 y 1 patient alive as of 39 mo 3/65 (5%) 29/65 (45%) Median survival: including Not reached at 22 mo arrhythmia (thymoma) 3.7 mo (sarcoma) 16.7 mo (NSCLC)
Perioperative Considerations
Postoperative Care
From the anesthesiologist’s standpoint, preparation for surgery includes the placement of routine monitors, lines, and an epidural catheter for perioperative pain control.25 An arterial line is mandated given the likelihood of rapid hemodynamic changes, and large bore intravenous access, including a central line, is recommended. If there is any question as to the possibility of existent pulmonary hypertension, the authors recommend placement of a Swan-Ganz catheter (which must be pulled back prior to division of the pulmonary artery). Central lines should be placed on the operative side to avoid pneumothorax on the side of the ventilated (and postoperatively, only) lung. Lung isolation may be obtained with double-lumen endotracheal tube (preferred) or bronchial blocker, with the latter to be pulled back prior to division of the bronchus. Finally, the authors recommend placement of a nasogastric tube to aid in identifying the esophagus intraoperatively and to decompress the stomach postoperatively. The extrapleural dissection and division of vagal fibers extending to the bronchus often lead to mild postoperative esophageal dysmotility, and nasogastric decompression may prevent lifethreatening aspiration in the early postoperative period in these patients with one remaining lung.
Surgery should be performed at centers in which surgeons, nurses, anesthesiologists, and additional clinicians providing perioperative and postoperative care are experienced with the course of patients undergoing EPP. Early recognition of subtle hemodynamic and/or respiratory changes can preempt life-threatening complications. For example, proper pneumonectomy space management can prevent fatal mediastinal shift.26 Avoiding postoperative death mandates immediate identification of tamponade, cardiac herniation, patch dehiscence, DVT, pulmonary embolus, and other morbidity.3 Finally, careful management of fluid status and pulmonary toilet is also critical to the postoperative care of these patients.
SUMMARY Although originally performed on patients with refractory tuberculosis and malignant pleural mesothelioma, extrapleural pneumonectomy may be used to treat patients with pleural dissemination of other malignancies, including thymoma and NSCLC. Patients who present with stage IV NSCLC caused by malignant pleural effusion may be considered for EPP following induction chemotherapy if they demonstrate no mediastinal
Extrapleural Pneumonectomy for Pleural Malignancies nodal or distant metastases and have adequate cardiopulmonary reserve. EPP for NSCLC should be performed by experienced teams at experienced centers to minimize the morbidity and mortality associated with this radical procedure. Additional prospective studies are needed to better characterize the role of EPP in the multimodality treatment of patients with pleural dissemination of malignancy, including NSCLC.
REFERENCES 1. Sarot IA. Extrapleural pneumonectomy and pleurectomy in pulmonary tuberculosis. Thorax 1949;4: 173–223. 2. Butchart EG, Ashcroft T, Barnsley WC, et al. Pleuropneumonectomy in the management of diffuse malignant mesothelioma of the pleura. Experience with 29 patients. Thorax 1976;31:15–24. 3. Sugarbaker DJ, Jaklitsch MT, Bueno R, et al. Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies. J Thorac Cardiovasc Surg 2004;128:138–46. 4. Sugarbaker DJ, Flores RM, Jaklitsch MT, et al. Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: results in 183 patients. J Thorac Cardiovasc Surg 1999;117:54–63 [discussion: 63–5]. 5. Flores RM, Pass HI, Seshan VE, et al. Extrapleural pneumonectomy versus pleurectomy/decortication in the surgical management of malignant pleural mesothelioma: results in 663 patients. J Thorac Cardiovasc Surg 2008;135:620–6. 6. Wolf AS, Daniel J, Sugarbaker DJ. Surgical techniques for multimodality treatment of malignant pleural mesothelioma: extrapleural pneumonectomy and pleurectomy/decortication. Semin Thorac Cardiovasc Surg 2009;21:132–48. 7. Flores RM. Surgical options in malignant pleural mesothelioma: extrapleural pneumonectomy or pleurectomy/decortication. Semin Thorac Cardiovasc Surg 2009;21:149–53. 8. Sugarbaker DJ, Wolf AS. Surgery for malignant pleural mesothelioma. Expert Rev Respir Med 2010;4:363–72. 9. Cao C, Tian D, Park J, et al. A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma. Lung Cancer 2014;83:240–5. 10. Rusch V, Baldini EH, Bueno R, et al. The role of surgical cytoreduction in the treatment of malignant pleural mesothelioma: meeting summary of the International Mesothelioma Interest Group Congress, September 11-14, 2012, Boston, Mass. J Thorac Cardiovasc Surg 2013;145:909–10. 11. Flores RM, Su W, Lal D, et al. Extrapleural pneumonectomy in children. J Pediatr Surg 2006;41:1738–42.
12. Wright CD. Extended resections for thymic malignancies. J Thorac Oncol 2010;5:S344–7. 13. Wright CD. Pleuropneumonectomy for the treatment of Masaoka stage IVA thymoma. Ann Thorac Surg 2006;82:1234–9. 14. Huang J, Rizk NP, Travis WD, et al. Feasibility of multimodality therapy including extended resections in stage IVA thymoma. J Thorac Cardiovasc Surg 2007;134:1477–83 [discussion: 1483–4]. 15. Ishikawa Y, Matsuguma H, Nakahara R, et al. Multimodality therapy for patients with invasive thymoma disseminated into the pleural cavity: the potential role of extrapleural pneumonectomy. Ann Thorac Surg 2009;88:952–7. 16. Bedini AV, Tavecchio L, Delledonne V. Extrapleural pneumonectomy for sarcomas report of two cases. Tumori 2000;86:422–3. 17. Sugarbaker DJ, Tilleman TR, Swanson SJ, et al. The role of extrapleural pneumonectomy in the management of pleural cancers. J Clin Oncol 2009;27:7577. 18. Greene FL. The American Joint Committee on Cancer: updating the strategies in cancer staging. Bull Am Coll Surg 2002;87:13–5. 19. Rami-Porta R, Crowley JJ, Goldstraw P. The revised TNM staging system for lung cancer. Ann Thorac Cardiovasc Surg 2009;15:4–9. 20. Rami-Porta R, Ball D, Crowley J, et al. The IASLC Lung Cancer Staging Project: proposals for the revision of the T descriptors in the forthcoming (seventh) edition of the TNM classification for lung cancer. J Thorac Oncol 2007;2:593–602. 21. Swanson SJ, Jaklitsch MT, Mentzer SJ, et al. Induction chemotherapy, surgical resection and radiotherapy in patients with malignant pleural effusion, mediastinoscopy negative (stage IIIB) non-small cell lung cancer. American Association for Thoracic Surgery 78th Annual Meeting Abstract Book 1998. Boston, May 3–6, 1998. 22. Ichinose Y, Tsuchiya R, Koike T, et al. Prognosis of resected non-small cell lung cancer patients with carcinomatous pleuritis of minimal disease. Lung Cancer 2001;32:55–60. 23. Suzuki K, Funai K, Shundo Y, et al. Extrapleural pneumonectomy after hyperthermo-chemotherapy for the lung cancer patients with malignant pleural effusion. Kyobu Geka 2004;57:1023–7 [in Japanese]. 24. Yokoi K, Matsuguma H, Anraku M. Extrapleural pneumonectomy for lung cancer with carcinomatous pleuritis. J Thorac Cardiovasc Surg 2002;123:184–5. 25. Ng JM, Hartigan PM. Anesthetic management of patients undergoing extrapleural pneumonectomy for mesothelioma. Curr Opin Anaesthesiol 2008;21:21–7. 26. Wolf AS, Jacobson FL, Tilleman TR, et al. Managing the pneumonectomy space after extrapleural pneumonectomy: postoperative intrathoracic pressure monitoring. Eur J Cardiothorac Surg 2010; 37:770–5.
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