Surgery
It meets several objectives, including controlling recurrent pleural effusion and maximum tumor cytoreduction.
The residual volume after cytoreduction surgery has a prognostic implication. (Pass, 1997).
5.1.1. Pleurectomy
Non-carcinological gesture, it should not be discussed outside of stages I.
5.1.2. Pleurectomy-decortication
It is feasible for TNM I stages with limited invasion of the visceral pleura (Bölükbas, 2011). The effect on survival is difficult to assess.
It must be discussed in the regional or national MESOCLIN RCP.
It is a significant but not carcinological resection of the visceral and parietal pleura preserving the lung and the diaphragm.
The objective of this surgery is to free the trapped lung by removing the visceral pleura. Excision of the parietal pleura can improve restrictive ventilation deficit and reduce pain.
This surgery can be performed by thoracotomy or video-assisted surgery (VATS).
The MesoVATS phase III trial compared video-thoracoscopic partial pleurectomy and talc pleurodesis. There is no increase in overall survival with partial pleurectomy but improvement in quality of life for up to one year. Talc pleurodesis is less expensive, has fewer side effects and reduces the length of hospital stay (Rintoul, 2014).
The morbidity of the thoracotomy decreases its interest, the video-assisted surgery takes a more important place by acting on the symptoms and being able to improve the survival (Halstead, 2005).
Enlarged pleurectomy-decortication involves diaphragmatic and / or pericardial resection (early stages T1 or T2N0).
Pleurectomy-decortication should not be offered as a curative intention but can be discussed for symptom control, especially if the lung is trapped and cannot benefit from chemical pleurodesis (recommendation, grade 2C), preferably performed by VATS (recommendation , grade 1C).
It must be preceded by an optimal tumor evaluation, thoraco-abdominal CT scan (pillars of the diaphragm), MRI of the diaphragm, evaluation of the lymph node extension by FDG PET (with histological evidence by mediastinoscopy, esophageal or bronchial echo-endoscopy for the sites 7, 4R, 4L, 2R) and remotely.
5.1.3. Radical surgery
This is the resection of all macroscopically tumor lesions of the hemithorax. The excision consists of an enlarged pleuro-pneumonectomy (EPP) "en bloc" (pleura, lung, pericardium, diaphragm, lymphadenopathy).
It concerns stages I and II (N0), in young patients able to tolerate pneumonectomy.
There is little evidence of the benefit of radical surgery on survival. Only studies that include radical surgery (PEP) in multimodal treatment show an improvement in survival. A few series have shown a median survival of 20-24 months (Sugarbaker, 2004; Rusch, 2001; Weder, 2007). Operative mortality is around 5% in specialized centers, but morbidity remains high (around 50%).
The characterization of the lymph node involvement is essential in the perspective of major surgery (by transesophageal ultrasound, trans-bronchial ultrasound, mediastinoscopy) because this usually makes resection rejected (Sugarbaker, 1993, 1999; Rusch, 1999 ).
Extended pleuro-pneumonectomy should only be undertaken after the advice of a national MESOCLIN SPC, by a team trained in this type of surgery, if possible in clinical trials. (recommendation).
5.2. Radiotherapy
5.2.1. Palliative irradiation
It is suitable for patients with pain due to parietal infiltration or tumor nodules (recommendation, grade 2C).
5.2.2. Prophylactic irradiation of drainage / thoracoscopy paths
An irradiation of 7 Gy / d for 3 consecutive days can be offered within 4 to 6 weeks after the procedure to prevent seeding on the path of the thoracocentesis (drainage, scars) (Boutin, 1995). This attitude is however contested by other authors (O'Rourke, 2007; Chapman, 2006).
European recommendations do not rule on the usefulness of prophylactic radiotherapy (Scherpereel, 2010).
Path irradiation should be discussed to reduce the incidence of permeation nodules (expert opinion).
5.2.3. Postoperative conformational radiotherapy (non-radical surgery)
Radiotherapy should not be offered after pleurectomy-decortication (lung in place) outside of clinical trials (new techniques) (recommendation, grade 1A).
5.2.4. Postoperative conformational radiotherapy (radical surgery)
Adjuvant irradiation could significantly reduce the risk of locoregional relapse after PEP (Rusch, 1999).
External irradiation of the hemithorax reached after PEP (50 to 54 gy) is recommended, and if possible offered
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