Document Qgy5VqKZDY77k76xK8kJwN2oL

THE NEW ENGLAND JOURNAL OF MEDICINE July 24, 1980 * Tabl* 2. Results ol Surgical Resection for Mesothelioma. |til Vaaa ho. or pwniwte - Terror Riumoai reaCaan or Panama SuavrviM) Yaaaioa Dniui-Faii Survival In in In Win" 1 174 Butchart ctal.11 Wanebo ctal." DcLaria ct el*4 Ariunanet al.J 1976 1976 1978 1980 IS6 Radical 75 34 9 Not apccified 62 Palliative" 68 37 10 Not apccified 29 Radical 30 10 3 3.5; 6 35 Pleurectomy NS 50 15 2 to 54 4 II Radical 36 27 0 2; 4 10 Pleurectomy 70 30 10 5 NS 4e%eut %o\ i^rctfird til * ptfUCMU. Wanebo et a!., 54 had exploratory surgery, and 33 had tumor resections (28 pleurectomies, two pleuropneumonectomies, and three lobectomies).11 Most patients also received radiotherapy and cyclophosphamide chemotherapy. Of the 33 resected patients, seven were free of disease at 17 to 69 months (median, 24). In addition, five relapsed but survived for five years or more. One perioperative death from myocar dial infarction occurred. In addition to disease-free survival resection resulted in a longer median survival time (as compared with patients treated with radio therapy or chemotherapy or both) and decreased morbidity from chest pain and recurrent pleural ef fusions." Critics note, however, that prolonged sur vival might have been expected in these selected patients with surgically approachable disease. Radiotherapy Prolonged survival and palliation of pain have been reported by French investigators after megavoltage ra diotherapy (median, 4500 rads) delivered to the in volved hemithorax." The study group survived a me dian of 13 months, as compared with 9.8 months for nonrandomized controls given conventional radiation therapy. In addition, intraperitoneal colloidal gold or chromic phosphate (>]P) have resulted in substantial palliation of symptoms and occasional cures in anec dotal cases.'-" Since the radionuclide can become loculated and cause tissue necrosis, this form of therapy is contraindicated in patients in whom either extensive adhesions or nodules larger than a few mil limeters in diameter are present at operation. Chemotherapy Response rates in small numbers of patients in dicate that doxorubicin (adriamycin) and the alky lating agents, including cyclophosphamide, are probably active single agents against mesothelioma'MMe; response rates are in the range of 20 to 40 per cent. Azacytidine and fluorouracil may also be ef fective."-'11 The efficacy of the other standard chemo therapeutic drugs has not been established in meso thelioma, although single case reports of objective responses to standard and investigational agents are sufficiently common to suggest that mesothelioma, unlike related sarcomas, is sensitive to a range of chemotherapeutic agents. Response rates approaching 30 to 40 per cent have been obtained with combination regimens containing doxorubicin, with palliation of symptoms and a longer median survival time for responding patients.,K Combined Treatments Although mesothelioma is widely believed to be resistant to conventional cancer therapy, both surgery and intracavitary radiotherapy have resulted in a few five-year disease-free survivals. Moreover, consider able palliation of recurrent pleural effusions and chest pain appears to rtsulft from pleurectomy. Patients treated at one center wilka combination of surgery, cyclophosphamide chemotneeapy, and radiotherapy survived for longer than those treated with only one or two of these methods." Since doxorubicin appears more effective than cyclophosphamide, the combina tion of surgery, radiotherapy, and a doxorubicincontaining chemotherapy regimen may improve palliation and increase the number of long-term disease-free survivors. An intensive combined ap proach, however, is clearly investigational and should be attempted only in cooperation with an ongoing prospective clinical trial. RrrrazNcrs 1. SelikofTIJ. Cancer riik ofaabciloicipoiurc. In: Hiatt HH, Waiaon JD, Winilcn JA. edi. Orijina of human cancer. Cold Sprint Hirboi, N.Y.: Cold Sprint Hirbor Laboratory, 1477:1765-14. 2. Animin KH. Blum RH. Grecnbcr|cr 7S, Flowerdcw G, Skarin AT, Candloi Of. Muliimodalily therapy for mali|ninl meioihelioma baled on a liudy of natural hinory. Am J Med. 1980; 68:)56-62. 2. Ocli HC, Harmon EO. Carr DT. Bcrnati PE. Diffuie mali|nanl meiotheliomi of the pleura: a ievic of }7 caaei. Chen. 1971; 60:564-70. 4. Elmci PC, Simplon MJC. The clinical eipccta of mcioihclioma. Q J Med. 1976: 45:427.49. 5. Lefha SS, Muptia FM. Pleural meioihelioma: clinical feature! and therapeutic implication!. Ann Intern Med. I977| 87:615-21. 6. Amman K. Clinical prcientation and natural hinory of benifn and melijnani mcioihclioma. Semin Oncol, (in pren). I 7. Moerlel CG. Peritoneal mcioihclioma. Gaitrocnteroloty. 1972; 65:546. 50. ; S. Okikc N, Bernati PE. Wootncr LB. Localiied Imeaolhelioma of the pleura: benign and miligmni varianti. J Thorac Cardiovjic Surj. 1978; 75:565-70. 9. Rotofl EE, Hilarn BS, Huvoi AG. Lont-term lurvival in patienti with malifnani peritoneal mcioihclioma treated with irradiation. Cancer. 1975; 52:656-64. 10. Sylman Al. MacAlpin RN. Primary pericardial mcioihclioma: report of two catei and review of the literature. Am Heart J. 1971; 81:760-9. 11. Waaler B. Eiienuein R, Battifora H. Elcctrophorciii of liuue |lyeoiamino|l>cam at an aid in the diafnom of metotheliomai. Cancer. 1979; 44:221-7. 12. Want N, Huant S. Gold P. Abience of carcinoembryonic antiien.likc material in mcioihclioma: an immunohinochemical differentiation from other lunt eanceri. Cancer. 1979. *4:957-45. 15. Aimer 2, Wiernik PH. Mali|nant mcioihclioma; current atatui and future proipecli Chell 1971: 74:458-44. 14. Butchart EG. Aihcrofl 7. Barnilcy WC. Holden M. Plcuropneumoneciomy in the mana|emcnt of diffuie mihjnani mcioihclioma of the pleura: ciperunce with 29 patienti. Thoraa. 1976; 51:15-24. 15. Wanebo HI. Martini N, Melamed MR. Hilarii B. Beattie I f Jr. Pleural mcioihclioma Cancer. 1976; 58:2481-8. 16. Dclaro GA. Jennl R, Faber P. Kittle F. Surfical mana,-cmcntj>f milifnam meioihelioma Ann Ihorac Surf 1978; 26:575-82. 17. WArn II MOftichkcncn und Ei|cbnntc dcr chirurfitchen Brhandlun| del malifnen Plcurameiothcliomi 1 horaichuvrfic. 1974; 22:591-5. IB. Schlicnycr M. tichc|t I. Blache R. Ocpierrc R. Mctotheliomci pleuraua mjlmi Bull Cancer (Parit). 1969; 56.265-508. 19. Icpha SS. Mupjoa IM Therapeutic approachei in mali|nant mciothelioma Cancer Treat Rev. 1917; 4.15-25. 20. Vap B, Benjamin RS. Butfcii MA. Bodey GP. The value of adriamy cin in the treatment of diffuie malt|nant pleural meioihelioma. Cancer. 1978; 42:1692-6 *- 8005 0034 - o-irr -rrTrrmtrvrrtrrrxBkr;,r- PRODUCED BY FORD