Thoracic surgical problems in asbestos-related disorders

Long-term outcome after resection of non-small cell lung carcinoma complicated by pneumoconiosis

PURPOSE

Lung cancer resection in patients with respiratory complications is associated with a high surgical risk and the operative indications are usually serious. Consequently, the long-term results are unclear. We aimed to clarify the validity of surgery for non-small cell lung cancer (NSCLC) in patients with pneumoconiosis.

METHODS

We reviewed the clinical and pathological data of 122 patients undergoing resection of NSCLC with pneumoconiosis (n = 34: group A) or without pneumoconiosis (n = 88: group B) to assess treatment outcomes and prognostic factors.

RESULTS

Among the treatment factors, intraoperative blood loss was significantly greater in group A (723.2 +/- 647.3 ml) than in group B (466.4 +/- 450.7 ml) (P = 0.0067), although the operative times (207 +/- 103.4 min vs 196.1 +/- 53.5 min, respectively) and postoperative drainage period (8.3 +/- 4.2 days vs 8.5 +/- 5.7 days, respectively) did not differ significantly between the two groups (P = 0.9466 and P = 0.6355, respectively). Among the postoperative complications, the incidence of hemorrhage was significantly higher in group A (29.4%) than in group B (7.9%) (P = 0.0022). The 5-year survival rates did not differ significantly between the two groups, (45.9% and 55.7% for groups A and B respectively) (P = 0.9424).

CONCLUSIONS

The coexistence of pneumoconiosis does not adversely affect postoperative survival or the treatment of NSCLC, although it is associated with increased intraoperative blood loss and postoperative hemorrhage. Thus, if precautions are taken to minimize hemorrhage, surgery cannot be excluded as a treatment option for NSCLC in patients with pneumoconiosis.

Pleurectomy/decortication for palliation in malignant pleural mesothelioma: results of surgery

OBJECTIVE

Surgery can only offer palliation in an attempt to slow the progression of malignant pleural mesothelioma (MPM). We want to assess the effectiveness and safety of pleurectomy/decortication in establishing a tissue diagnosis, and controlling pleural fluid accumulation and symptoms in patients with MPM.

METHODS

We reviewed our pleurectomy results in 100 patients with MPM over a 19 year period. Major symptoms were chest pain, cough and dyspnea, and radiographic findings included pleural mass, pleural fluid and constriction of involved hemithorax.

RESULTS

Approximately two thirds of the patients underwent surgery prior to tissue diagnosis. Eighty-nine patients had stage I and stage II disease, 8 and 81%, respectively. The patients underwent subtotal (44%) or total pleurectomy (56%). The surgical mortality rate was 1% (1/100) and the morbidity rate was 22%. Morbidity included prolonged air leak (n = 12), empyema (n = 6), reaccumulation of pleural fluid (n = 2) and wound infection (n = 2). Palliative results included dyspnea and cough relief in all patients, chest relief in 60 (85%) and pleural fluid control in 52 (96%) patients. Median survival was 17 months in MPM patients.

CONCLUSIONS

We conclude that pleurectomy/decortication safely provides both tissue diagnosis and effective of pleural effusion and symptoms and therefore excellent palliation in patients with MPM.

A proposed new international TNM staging system for malignant pleural mesothelioma from the International Mesothelioma Interest Group

STUDY OBJECTIVE

investigation of the behavior and treatment of diffuse malignant pleural mesothelioma (MPM) is hindered by the lack of an accurate universally accepted staging system. To address this problem, the International Mesothelioma Interest Group (IMIG) has developed a new TNM based staging system.

METHODS

the staging system was developed at a consensus meeting of IMIG members involved in clinical research in MPM, including the originators of previously proposed staging systems. The new staging system is based on the analysis of emerging information about the impact of T and N status on survival.

RESULTS

in contrast to five previous staging systems, the T descriptors designated as T1, T2, T3 and T4, provide precise anatomic definitions of the local extent of the primary tumour. The N descriptors, designated as N0, N1, N2 and N3, are virtually identical to those used in the International Lung Cancer Staging System. The stage groupings recognize new data about the better prognosis of T1 and N0 tumours and classify those tumours into stages I and II. The adverse impact of nodal metastases on survival noted in some recent surgical series warrants placing node positive tumours in stage III. Locally advanced unresectable (T4) tumours and extrathoracic disease (N3 or M1) are classified as stage IV.

CONCLUSION

this proposed staging system reconciles and updates several earlier systems, and can provide the framework for analyzing the results of prospective clinical trials aimed at improving the currently dismal prognosis of MPM.

Asbestos-cement pneumoconiosis: first surgically confirmed case in Kuwait

During the periodic medical examination of workers of the only asbestos-cement pipe factory in Kuwait, an early case of asbestosis was diagnosed. It was the first case of asbestosis to be reported and compensated in Kuwait. According to available information, it is also the first reported case to be confirmed by surgery in the Arabian Gulf countries. Recommendations are given in regard to diagnosis, the institution of very strict preventive and protective measures, and the system of compensation in Kuwaiti law.

Surgical treatment of asbestos-related disease of the chest

Thoracic surgeons are asked to evaluate various diseases related to asbestos, including benign pleural plaques, malignant mesothelioma, and lung cancer. The benign localized mesothelioma is usually considered in the differential diagnosis of pleural tumors, but it is not related to asbestos exposure. Benign pleural plaques can be diagnosed by history and radiologic studies, and surgery offers no therapeutic benefit. Diffuse malignant mesothelioma is currently an incurable tumor, but pleurectomy can afford some palliation. Extrapleural pneumonectomy can be accomplished with an acceptable mortality, but long-term results do not justify its routine use. Lung cancer in those exposed to asbestos fibers is treated no differently than when it occurs in the general population.

Asbestos-related malignancy

Due to the known association with asbestos exposure, malignant mesothelioma has assumed an importance out of proportion to its incidence in the American population (2.2 per million). Patients present with chest pain, shortness of breath, or both. The initial chest X-ray generally reveals a large unilateral pleural effusion. A large piece of tissue obtained via open biopsy is usually required for histologic diagnosis. Investigational approaches include multiple needle biopsies obtained for electron microscopy, as well as for immunoperoxidase staining for keratin and CEA. The tumor characteristically remains localized until late in its course. The treatment of mesothelioma remains unsatisfactory. However, anecdotes report long-term disease-free survival after intensive treatment. Palliation with a response rate of up to 30% to various chemotherapeutic regimens has been reported by a number of investigators.