Extrapleural Pneumonectomy in the Treatment of Malignant Pleural Mesothelioma David J. Sugarbaker, MD, Steven J. Mentzer, MD, and Gary Strauss, MD Divisions of Thoracic Surgery and Hematology/Oncology, Brigham and Women's Hospital, Boston, Massachusetts

A technique for extrapleural pneumonectomy in diffuse,

malignant, pleural mesothelioma is described. The technique used in a protocol at Brigham and Women's Hospital has resulted in improved operative mortality figures and length of hospital stay. The right-sided procedure is presented followed by differences in technique required by the left-sided approach. (Ann Thorac Surg 1992;54:941-6)

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xtrapleural pneumonectomy has been used by thoracic surgeons in the treatment of tuberculous empyema [l-31 as well as other pleural diseases such as malignant pleural mesothelioma [P16]. Initial series reporting the efficacy of this procedure in mesothelioma were colored by its relatively high reported operative mortality [5, 61 when compared with standard pneumonectomy [17]. Over the last 8 years we have gained substantial experience in our institution with a procedure in the treatment of diffuse malignant pleural mesothelioma in a protocol using pleural pneumonectomy, cyclophosphamide, doxorubicin, and cisplatin (CAP) chemotherapy, and radiotherapy. Our surgical technique has evolved, and our operative mortality and length of hospital stay have continued to decrease. We present a detailed account of our current technique of pleural pneumonectomy resecting lung, parietal and visceral pleura, pericardium, and diaphragm. Our technique differs from previous descriptions of the procedure [9, 181. The technique for pleural mesothelioma varies depending on whether the procedure is performed on the right or the left side. We describe the surgical approach to the right side. After this, a brief description of the unique aspects of a left-sided approach will be discussed.

Material and Methods

Patient Selection Patients selected for extrapleural pneumonectomy are those who have been enrolled in a protocol in which this technique is used as a means of control of the primary tumor. Resection is attempted only in Butchart clinical stage I and I1 patients. Primary resection is then followed by CAP chemotherapy and radiotherapy. Other adjuvant Accepted for publication March 19, 1992. Address reprint requests to Dr Sugarbaker, Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.

0 1992 by The Society of Thoracic Surgeons

chemotherapy protocols are currently in development in both the United States and Europe [19, 201. Selection of patients for the procedure is based on the usual parameters for defining operability in pneumonectomy patients. The use of forced expiratory volume in 1 second, as well as other dynamic spirometry testing in addition to functional oximetry, is helpful in defining these patients. In borderline recipients, the use of quantitative ventilation perfusion scanning may be of substantial benefit in predicting postoperative pulmonary function. We use preoperative echocardiography to define ventricular function in this group of patients who are destined to receive doxorubicin as an adjuvant therapy. We have found the echocardiogram helpful in determining which patients will be able to sustain, not only the pneumonectomy, but also these postoperative adjuvant treatments. This baseline echocardiogram is used midway through the course of postoperative chemotherapy to further detect possible cardiac toxicity. Preoperative chest magnetic resonance imaging has proved of substantial benefit in helping us determine extent of disease preoperatively, particularly the sagittal planes demonstrating evidence of disease in the paravertebral sulcus or disease extending through the diaphragm. In addition sagittal cuts are of help in predicting mediastinal involvement of the cava, esophagus, or trachea. The presence of any one of these findings precludes any attempt at operative resection. In the cases where transdiaphragmatic involvement is suspected but not proven, a limited laparotomy is performed so that the surgeon may perform an inspection of the liver to determine the presence or absence of actual invasion. We have found the use of routine preoperative echocardiography and magnetic resonance imaging extremely helpful in decreasing the number of patients in whom operative resection is precluded at the time of surgical exploration. Clean surgical margins have not been shown to be of any benefit in predicting survivors in this disease [16], although every attempt is made for as complete a cyforeductive procedure as possible.

Technique The incision for right-sided pleuropneumonectomy is an extended right thoracotomy along the course of the sixth rib (Fig 1).The incision is carried from the posterior aspect of the thorax, midway between the posterior scapular ridge and the spine, along the bed RIGHT-SIDED LESION.

0003-4975/92/$5.00

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Trachea

Subclavian vessels

Right main bronchus

Fig 2 . Right main bronchus identified.

Fig 1 . Extended right thoracotomy incision.

of the sixth rib to the costochondral junction. A subperiosteal resection of the sixth rib is then performed to provide wider exposure and to readily facilitate entrance into the extrapleural plane. The periosteum is opened and a broad-based dissection is then begun superiorly toward the apex using blunt and sharp techniques. The dissection is completed along the anterior lateral aspect superiorly and then begun in a similar fashion inferiorly and laterally to the diaphragm. Care is taken to avoid dissection posterior to the azygos vein until wider exposure has been gained. At this time two chest retractors are placed anteriorly and posteriorly. Continued blunt and sharp dissection occurs up to the cupola of the lung. Care is taken to palpate the course of the subclavian artery and to maintain the plane between the parietal pleural and these vessels. Care is then taken to preserve the internal mammary artery and vein, which often pass through the extrapleural plane superomedially. If mistaken for adhesions, these can be avulsed from either the superior vena cava or the subclavian artery. Small adhesions are divided, staying close to the pleural plane in the extrapleural fat. The dissection is then carried immediately from the apex of the lung to the azygos vein. Dissection is carried extrapleurally until the right upper lobe and main bronchus are clearly identified (Fig 2). The cava and azygos vein are then dissected with sharp as well as blunt dissection from the parietal pleural structures. Care is taken to prevent avulsion of the vein. The dissection is then continued anteriorly and inferiorly to the circumferential diaphragmatic margin. A nasogastric tube is placed and facilitates palpation of the esophagus to preserve it from damage. The dia-

phragm is opened posterolaterally in a radial fashion to the anterior medial aspect of the pericardium. Care is taken to keep the pleural envelope intact; in certain situations this requires dissection of the pleural envelope off the diaphragm before its division (Fig 3). Care is taken when dividing the diaphragm to preserve the underlying peritoneum. Blunt dissection is then used to wipe the peritoneum off the diaphragm with the aid of a sponge stick (Fig 4). Once the diaphragm has been divided anterolaterally to the pericardium it is then divided along the caval and esophageal hiatuses. This may be facilitated by entering the pericardium to define the course of the inferior vena cava through the diaphragm. The diaphragm and pleural envelope are then divided just lateral to the inferior cava and esophagus (Fig 5). The diaphragmatic incision is then completed. The pericardium is then formally opened anteromedially to the phrenic nerve and the hilar vessels (Fig 6 ) .Care is taken to keep the parietal pleural envelope intact. The main pulmonary artery is dissected free from the cava and underlying superior pulmonary vein (Fig 7). The

Fig 3. Dissection of the pleural envelope off the diaphragm.

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Phrenic n e r v e

Fig 4. Peritoneum wiped of the diaphragm with a sponge.

intrapericardial right pulmonary artery is then divided between two vascular staple lines (see Fig 7) [21]. Once the pulmonary artery has been divided the superior pulmonary veins are likewise divided. The pericardium is divided posterior to the hilum to complete the pericardial resection. The specimen is then elevated and dissection continued posterior to the pericardium and lateral to the esophagus. A subcarinal node dissection is performed at this time. The main bronchus is then dissected to the carina and stapled using a heavy-gauge bronchial stapler (Fig 8). The specimen is removed. A pericardial fat pad is then elevated (Fig 9) and placed over the bronchial stump. Then the pericardium is closed with a prosthetic patch using a monofilament suture (see Fig 9). The pericardium is always reconstructed on the right side to prevent cardiac herniation, a potentially fatal

Fig 6. The pericardium is opened anteriorly medial to the phrenic nerve and hilar vessels.

complication. Fenestrations are created in the patch to prevent tamponade. Reconstruction of the diaphragm is then carried out. If peritoneal covering remains intact, multiple sutures of 0 Vicryl are used in a reefing fashion (Fig 10) to provide strength to the overlying peritoneum. The sutures are anchored in the chest wall (Figure 10). No further reconstruction is carried out. If the peritoneum was not spared during dissection, a prosthetic impermeable patch is placed and sewn in place with a running monofilament 0 suture (Fig 11).We have

Right lung

\ Visceral pleura Fig 5 . Diaphragm and pleural envelope divided lateral to inferior cava and esophagus.

Fig 7 . The intrapericardial right pulmonay a r t e y is divided by two staple lines.

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Fig 8. The main bronchus is dissected to the carina and stapled.

found the use of impermeable membranes prevents rapid filling of the chest cavity by peritoneal fluid. This rapid filling can produce mediastinal shift or tamponade in the early postoperative period before mediastinal stabilization has occurred. The chest is then closed in multiple layers to assure watertight closure. A red rubber catheter remains until the skin is closed, and air (750 mL in women, 1,000 mL in men) is removed in the immediate postoperative period before leaving the operating room. A chest roentgenogram is obtained in the recovery room, and the catheter is

Fig 9. A pericardial fat pad has been sewn to cover the bronchial stump; the pericardium is closed with a patch, and fenestrations are made in the patch.

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\

Anchoring suture in chest wall Fig 10. Reconstruction of the diaphragm using multiple sutures of 0 V i c y l in a reefing fashion is carried out; the sutures are anchored to the chest wall.

removed if the mediastinum is midline. Air can be instilled or removed to balance the mediastinum if a shift is seen, and then the catheter is removed before the patient leaves the recovery room. Alternately, if oozing is present, a chest tube can be left to waterseal overnight. Surgical specimens are assessed for resection margins in multiple areas. If gross disease, although limited, is left behind, it is outlined with clips for subsequent radiotherapy.

Fig 11. A prosthetic impermeable patch is sewn in place where the peritoneum has been removed.

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procedure. Aggressive use of the electrocautery is encouraged. In addition, rapid packing of areas after completion of dissection in that region is undertaken. After removal of the specimen, sheets of Surgicel (Johnson &Johnson, Arlington, TX) are placed over the raw chest wall surface. Packs are then placed on them and several minutes of tamponade is allowed to ensure a dry closure.

. Pulmoi artery

!fi lung

4 Fig 12. The pulmonary arte ry extrupericurdial and extrapleural ready to be dissected.

The approach for left-sided lesions is similar to that on the right. In our experience the procedure is technically easier on the left side due to the absence of the caval and esophageal hiatus. Subtle differences do exist. Less air needs to be removed from the left at the end of the procedure (500 mL in women; 750 mL in men). In dissecting the medial aspect of the specimen in the posterior region, care must be taken to enter the correct plane in the preaortic region. One can get into an incorrect retroaortic plane and produce bleeding from avulsing the intercostal vessels. Care must be taken to assess tumor involvement of the aorta at this time. Once the specimen has been circumferentially dissected from the chest wall, the diaphragm is divided in a radial fashion along the left side with care being taken to spare the aorta at the hiatus. The pericardium is then entered inferiorly and the vessels identified. Unlike on the right side, we prefer to dissect the extrapleural left main pulmonary artery as it leaves the pericardium and enters the left chest. The pulmonary artery is divided in its extrapericardial, extrapleural position (Fig 12) using two vascular staple lines. The veins are taken from within the pericardium. The pericardial resection is then completed posteriorly. The left main bronchus must be dissected for a greater distance to ensure a short bronchial stump. The bronchial stump is covered, the diaphragm reconstructed, and chest closed as on the right side. The pericardium is not routinely reconstructed on the left side because the risk of cardiac hemiation is low on the left as opposed to the right. LEFr-sIDED LESION.

H E M O S T A S I S . Hemostasis

during extrapleural pneumonectomy is a vital component to successful completion of this

Clinical Results and Comment The principles of this technique have been used in 44 consecutive cases of pleural pneumonectomy at the Brigham and Women's Hospital. Operative mortality was 4.6% (2 patients) and morbidity, 30% (13 patients). The mean length of stay was 10.2 t 4.5 days for the 42 patients who survived operation. The use of pleural pneumonectomy may be of increasing value in achieving cytoreduction in pleural malignant mesothelioma. As noted by others, the successful accomplishment of local control in this disease continues to exert substantial pressure for new and more effective chemotherapeutic adjuvant therapy [lo]. It appears clear that in a disease where salvage rates of 15% to 20% over 5 years would represent a major advance, operative mortality rates must be held well below comparable levels if pleural pneumonectomy is to become a viable therapeutic alternative as a component of a multimodality approach to mesothelioma.

References 1. Hood RM, Antman K, Boyd A, Naidich D, Shemin R. Surgical diseases of the pleura and chest wall. Philadelphia: W. B. Saunders, 1986:126. 2. Sabiston DC Jr, Spencer FC. Surgery of the chest, 5th ed, vol I. Philadelphia: W. 8. Saunders, 1990:705-6. 3. Sarot IA. Extrapleural pneumonectomy and pleurectomy in pulmonary tuberculosis. Thorax 1949;4:173-223. 4. Worn H. Moglichkeiten und Ergebnisse der chirurgischen Behandlung des malignen Pleuramesotheliomas. Thoraxchir Vask Chir 1974;22:391-3. 5. Bamler KJ, Maassen W. The percentage of benign and malign pleura-tumors among the patients of a clinic of lung surgery with special consideration of the malign pleuramesothelioma and its radical treatment, including results of a diaphragm substitution of preserved dura mater. Thoraxchir Vask Chir 1974;22:386-91. 6. Butchart EG, Ashcroft T, Barnsley WC, Holden MP. Pleuropneumonectomy in the management of diffuse malignant mesothelioma of the pleura. Experience with 29 patients. Thorax 1976;31:15-24. 7. DeLaria GA, Jensik R, Faber LP, Kittle CF. Surgical management of malignant mesothelioma. Ann Thorac Surg 1978;26: 375-82. 8. Butchart EG, Ashcroft T, Barnsley WC, Holden MP. The role of surgery in diffuse malignant mesothelioma of the pleura. Semin Oncol 1981;8:321-8. 9. Faber LP. Malignant pleural mesothelioma: operative treatment by extrapleural pneumonectomy. In: Kittle CF, ed. Current controversies in thoracic surgery. Philadelphia: W. 8. Saunders, 1986:804. 10. Antman KH, Shemin RJ, Corson JM. Malignant pleural mesothelioma: a combined modality approach. In: Kittle CF,

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ed. Current controversies in thoracic surgery. Philadelphia: W. B. Saunders, 1986:68-75. 11. DaValle MJ, Faber LP, Kittle CF, Jensik RJ. Extrapleural pneumonectomy for diffuse, malignant mesothelioma. Ann Thorac Surg 1986;42:612-8. 12. Falkson G, Alberts AS, Falkson HC. Malignant pleural mesothelioma treatment: the current state of the art. Cancer Treat Rev 1988;15:23142. 13. Dogan R, Cetin G, Moldibi B, et al. Traitement chirurgical du mesotheliome pleural. Rev Pneumol Clin 1988;44:57-63. 14. Landa L, Fianchini A, Gesuelli GC, Catalini GB, Fonti M. I1 ruolo della chirurgia nel trattamento del mesotelioma pleurico. Chir Ital 1989;41:192-206. 15. Harvey JC, Fleischman EH, Kagan R, Streeter OE. Malignant pleural mesothelioma: a survival study. J Surg Oncol 1990; 45:40-2. 16. Sugarbaker DJ, Heher EC, Lee TH, et al. Extrapleural pneumonectomy, chemotherapy, and radiotherapy in the treat-

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ment of diffuse malignant pleural mesothelioma. J Thorac Cardiovasc Surg 1991;102:10-5. Choi NC, Mathisen DJ, Huberman MS, Mark EJ. Cancer of the lung. In: Cancer manual, 8th ed. Boston: American Cancer Society, Massachusetts Division Inc, 1990:198. Kittle CF. Pleural mesothelioma. In: Grillo HC, Austen WG, Wdkins EW Jr, Mathisen DJ, Vlahakes GJ, eds. Current therapy in cardiothoracic surgery. Toronto: 8. C. Decker, 1989:114-6. Boutin C, Viallat JR, Astoul P. Treatment of mesothelioma with interferon gamma and interleukin 2. Rev Pneumol Clin 1990;46:211-5. Boutin C, Viallat JR, Van Zandwijk N, et al. Activity of intrapleural recombinant gamma-interferon in malignant mesothelioma. Cancer 1991;67:2033-7. Sugarbaker DJ, Mentzer SJ. Improved technique for hilar vascular stapling. Ann Thorac Surg 1992;53:165-6.

Notice From the American Board of Thoracic Surgery The part I (written) examination will be held at the Hilton Executive Conference Center, Dallas Fort Worth Airport, Dallas, TX, on February 13, 1994. The closing date for registration is August 1, 1993. To be admissible for the part I1 (oral) examination, a candidate must have successfully completed the part I (written) examination.

A candidate applying for admission to the certifying examination must fulfill all the requirements of the board in force at the time the application is received. Please address all communications to the American E h r d of ThOracic Surgery, One Rotary Center, Suite 803, Evanston, IL 60201.

Extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma.

A technique for extrapleural pneumonectomy in diffuse, malignant, pleural mesothelioma is described. The technique used in a protocol at Brigham and W...
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