Treatment of Malignant Pleural Mesothelioma: Pleurectomy with Adjuvant Therapy

TPR

Tamrdjri

ltsrntnpC

IMengatotbS3erma

*

†

A

1d

reatment of Malignant Pleural Mesothelioma:leurectomy with Adjuvant Therapy

aja M. Flores, MD,* and Naveed Alam, MD†

Psto

fittFoa

IIoowpttfioiatt

rsdtaSasco

PAi

he epidemiology of mesothelioma first came to light in1960 with the report by Wagner and colleagues of 33

sbestos mine workers from South Africa who developedesothelioma.1 Malignant pleural mesothelioma (MPM) is a

are tumor but the geographical distribution of the disease isiverse; taken as a whole, the United States has an incidence

ust under 1 per 100,000. However, the incidence has beenising since the 1970s. The male-to-female ratio is 5:1, whichs likely due to the occupational exposure of asbestos.

Staging in MPM, as is the case in other aspects of the disease,acks consensus. Various staging systems exist. The classic sys-em described by Butchart and colleagues in 1976 is relativelyimple and descriptive.2 The Brigham staging system is based onesectability by extrapleural pneumonectomy (EPP) and mayot be of value in patients undergoing pleurectomy and decor-ication (P/D). The TNM staging system proposed by the Inter-ational Mesothelioma Interest Group (IMIG) is the most com-rehensive and is accepted by the American Joint Committee onancer (AJCC) and International Union Against Cancer (UICC).

ndications for SurgeryPM was thought to be uniformly fatal in the days before

ffective systemic therapy. Surgery was reserved for diag-osis and palliation. In the first reports of “curative” sur-ery, Butchart and colleagues (1976) performed EPP withsurgical mortality of 30%.2 In the nearly 30 years since

he initial report, advances in patient selection and intra-perative and postoperative management have substan-ially decreased the mortality of the operation as reportedy centers with high volumes of mesothelioma surgery.ugarbaker and colleagues reported their mortality from28 consecutive EPP performed at the Brigham and Wom-n’s Hospital as 3.4%.3 At Memorial Sloan-Kettering, weeported a 5.2% mortality for EPP. The staggeringly highortality seen in early attempts at EPP led to a movement

way from this operation and toward P/D. The mortality of

Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Can-cer Center, New York, New York.

Peter MacCallum Cancer Centre and St. Vincent’s Hospital, Melbourne,Australia.

ddress reprint requests to Raja M. Flores, MD, Thoracic Service, Depart-ment of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 YorkAvenue, Room C-879, New York, New York 10021; E-mail:

[email protected].

522-2942/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.oi:10.1053/j.optechstcvs.2006.02.002

/D is reported as l.8% and the lack of evidence demon-trating superiority of EPP over P/D was thought to be dueo the up-front mortality increase with the more extensiveperation.There are those who still believe that surgical intervention

or purposes other than palliation in mesothelioma is notndicated. While it is true that there are no randomized con-rolled trials comparing surgical treatment to supportive care,he reality is that these trials will likely never be performed.or those who treat this disease and have a less nihilisticutlook, surgery forms a key component of the treatmentlgorithm.

ndications for P/Dndications for P/D can be thought of as being patient relatedr tumor related. Perhaps the least controversial statementne can make about P/D is that it can be offered to patientsho do not have the cardiopulmonary reserve to tolerateneumonectomy. For patients who can tolerate pneumonec-omy, the choice of operation becomes less clear. Some cen-ers perform P/D for patients with early-stage disease, con-ned to the parietal pleural “capsule” (Butchart I, IMIG T1a,r T1b), the reasoning being that if no lung parenchyma isnvolved the inherent morbidity and mortality risk of addingpneumonectomy is not warranted. Others disagree, feeling

hat the absence of lung parenchyma facilitates the adminis-ration of postoperative adjuvant radiotherapy.

If one accepts that MPM is a disease where true R0esections are a theoretical achievement, then the goal ofurgery is to remove all gross tumor and serve as a foun-ation for adjuvant therapy. The choice of operation canhen be made based on the extent of resection requirednd the extent of resection that the patient will tolerate.ome clinicians feel that with newer methods of radiationdministration and ongoing attempts at other local andystemic therapies, the argument that residual lung paren-hyma hinders appropriate adjuvant therapy may be lessf a factor than it once was.

reoperative Evaluationll patients undergoing consideration for P/D need thorough

maging and cardiopulmonary evaluation. At a minimum,
ulmonary function testing should be performed. Quantita-
57

tcsuiwrPMtPt

uSM

odthrmd

58 R.M. Flores and N. Alam

ive ventilation perfusion scans may also be indicated if asso-iated lung resections are anticipated or to evaluate the pos-ibility of EPP. Computed tomography of the thorax andpper abdomen is required imaging and magnetic resonance

maging may be superior in assessing discrete focuses of chestall invasion or diaphragmatic muscle involvement but

arely changes surgical decisions.4 18Fluorodeoxyglucoseositron Emission Tomography (FDG-PET) scanning inPM can be used to provide stage and prognostic informa-

ion. In addition to helping to determine the extent of tumor,ET can be used to detect N3 or M1 disease in 10% of pa-
ients.5,6 The standardized uptake value (SUV) can also be t
sed to predict the presence of N2 lymphatic spread.6 HighUV has also been shown to correlate with poor survival inPM.7

Another controversial question in the preoperative evaluationf patients is the role of mediastinoscopy in MPM. It is useful inetermining the N-stage of most patients and is more accuratehan computed tomography. However, up to 25% of patientsave lymph node involvement confined to areas of the hemitho-ax inaccessible by mediastinoscopy such as the peridiaphrag-atic or internal mammary regions. Furthermore, although N2isease does negatively impact survival, it should not be used as
he sole criteria to deny someone surgery.

Treatment of malignant pleural mesothelioma 59

Operative Technique

Figure 1 Patient in the lateral decubitus position. Following the induction of general anesthesia, a double lumenendotracheal tube should be inserted to facilitate the operation. An arterial line and central venous pressure monitoringare important as blood loss is often significant. The patient is placed in the lateral decubitus position and an extendedposterolateral thoracotomy incision extending downwards to the costal margin is made.


Figure 2 Sixth rib removed. The sixth rib is resected and the dissection is begun in the plane between the endothoracic
fascia and the parietal pleura. The pleural tumor is bluntly dissected away from the chest wall.


Figure 3 Dissection of the extrapleural plane. The plane is then developed in a cephalad direction toward the apex from
the posterolateral direction using blunt and sharp dissection.


Figure 4 Exposure of extrapleural thoracic cavity is facilitated by the placement on two finnechetto retractors. After asufficient area of chest wall has been mobilized, two chest retractors facilitate exposure. Care in identifying thesubclavian vessels is prudent as a traction injury to these structures is difficult to repair. As each area of dissection iscompleted, packs are placed to aid in hemostasis as a fair amount of blood loss will result from the blunt dissection. The
dissection is then continued inferior and posterior from the incision to the diaphragm.


Figure 5 (A) Superior dissection of subclavian artery and aortic arch. (B) Superior dissection of SVC and azygous vein.The pleura can now be mobilized from the mediastinum. Once the upper portion of the lung is completely mobilizedfrom the chest wall, the superior and posterior hilar structures are well exposed. On the left side, the esophagus andaorta must be identified and the dissection around them undertaken with care (A). On the right side, the superior venacava must be dissected away from the specimen gently (B). The dissection then continues to the posterior aspect of the
pericardium. SVC � superior vena cava.


Figure 5 Continued


Figure 6 (A) Lateral dissection of descending aorta and esophagus. (B) Lateral dissection of carina and esophagus. Onthe left, care must be taken not to injure the descending aorta (A). On the right, a nasogastric tube helps to identify theesophagus by palpation (B). A plane between the mediastinal pleura and the pericardium is sometimes present. If it is
not, the pericardium needs to be resected en bloc at a later stage of the operation with subsequent reconstruction.


Figure 6 Continued


Figure 7 Diaphragmatic fibers are cauterized while the inferior portion of the specimen is retracted cephalad. Thedissection is then carried toward the posterior diaphragmatic sulcus. If superficial involvement of the diaphragm isfound, a partial thickness resection can be performed. The plane between the tumor and the uninvolved diaphragm canbe entered and the dissection is initiated at the posterior costophrenic angle and carried anteriorly. This is facilitated bystrong retraction on the pleura away from the diaphragm. In many patients deeper involvement of the diaphragmmandates a full-thickness resection of a portion of the muscle. The deep border of the diaphragm must then bedissected from the peritoneum. Care should be taken to avoid entering the abdomen as tumor seeding into theperitoneal cavity is a concern. This is often unavoidable, especially around the central tendon, and any defect in theperitoneum should be closed immediately. The specimen is then mobilized en bloc back toward the pericardiummedially. If resection of the pericardium is required, it is delayed until the tumor is mobilized as much as possible dueto the accompanying arrhythmias from manipulation. The pericardium is gradually opened and traction sutures areplaced on the nonspecimen edge to maintain the position of the heart and prevent retraction of the pericardium into the
opposite hemithorax.


Figure 8 Visceral pleura is separated from the underlying lung by sharp and blunt dissection. Once the dissection iscompleted to the hilar structures, the parietal pleura is opened and the pleural envelope is entered and decortication of
the visceral pleura from the underlying lung and hilar vessels is performed.


Figure 9 (A) Sharp and blunt dissection separates lobes. (B) Sharp dissection to remove visceral pleura tumor offfissures. (C) Careful dissection of pleura from underlying pulmonary artery. This is, in some respects, the mosttechnically demanding and tedious component of the operation. Decortication must be performed with care into thefissures because they are often substantially involved with disease. During the decortication, deflation of the lung willminimize blood loss and inflation will allow better visualization of the plane between the tumor and the visceral pleuraor lung parenchyma. Communication with the anesthesiologist about the amount of blood loss is important as patientsmost often require intraoperative transfusion.

Lymph node dissection should be performed and specimens sent and labeled separately to the pathologist. Thesubcarinal lymph nodes should be resected as well as the paratracheal lymph nodes on the right and aorto-pulmonary
lymph nodes on the left.


Figure 9 Continued


Figure 10 If enough diaphragm remains, it is usually defunctionalized and requires plication. Once the gross tumor isremoved and the specimen is delivered, reconstruction of the pericardium and diaphragm, if required, are performed.If the diaphragm is largely intact, it can be closed primarily by plication to prevent upward movement and subsequentcompression atelectasis of the lower lobe. On the right side, reconstruction of the diaphragm is performed with adouble layer of Dexon mesh as the liver prevents herniation of intraabdominal contents. On the left, 2-mm-thicknessGore-Tex is used because thicker nonabsorbable material is required to prevent herniation. The prosthesis is securedlaterally by placing sutures around the ribs. Posteriorly it is sutured to the crus or tacked to the prevertebral fascia. Themedial aspect is sewn to the remaining edge of the diaphragm at its confluence with the pericardium. The diaphrag-matic prosthesis should be made absolutely taut to prevent upward motion of the abdominal contents and subsequentatelectasis of the lower lobe. If the pericardium was resected, it is reconstructed with a single layer of Dexon mesh.

Attention is now turned to obtaining hemostasis. An argon beam electrocoagulator may be used to help controldiffuse bleeding from the chest wall. Three chest tubes are placed anteriorly and posteriorly into the apex and a rightangle tube along the diaphragm. This should allow for control of the substantial air leaks that are anticipated and permit
full expansion of the lung. The air leaks tend to resolve after 72 hours if the lung is fully expanded.

PDwjtmtts

nat

cs

RPatoef

pcmr

CSiabtttas

PSepKwpst

pldomMm

9m

dr8d

o3dtt1trd

ot

PaRbctrercww

1cmm

wctas2

fms

rnttcgup


itfallsuring the dissection, certain areas of particular concernarrant special mention. The subclavian vessels can be in-

ured by traction during the blunt dissection of the apex. Onhe right, care needs to be taken in the dissection of theediastinal pleura from the superior vena cava. On the left,

he plane between the tumor and the adventitia of the aorta,he origins of the intercostal vessels, and the esophagus,hould all be identified.

If the diaphragm is largely left intact and reconstruction isot undertaken, plication is often helpful to prevent elevationnd paradoxical motion of the diaphragm and atelectasis ofhe lower lobe.

While prior talc pleurodesis is not an absolute contraindi-ation to the operation, it does increase the likelihood ofubstantial blood loss and air leak.

esults/D is generally well tolerated with a mortality limited topproximately 1 to 2% when performed at high volume cen-ers. The most common complication is prolonged air leakccurring in 10% of patients. Hemorrhage, pneumonia, andmpyema are less common complications. Median survivalsor P/D alone range from 9 to 20 months in the literature.

The technical challenge of separating tumor and visceralleura from the lung parenchyma may result in suboptimalytoreduction. This is reflected in the observation that theost common site of recurrence is the ipsilateral hemitho-

ax.8

ombined Modality Therapyince the results of surgery alone are poor, most recent stud-es have combined P/D with some form or combination ofdjuvant therapy. These have included external radiation,rachytherapy, systemic chemotherapy, intrapleural chemo-herapy, and photodynamic therapy. It is important to notehat these studies are almost uniformly observational in na-ure. When comparisons are performed, they are by and largecross inhomogeneous groups, thereby limiting the conclu-ions that can be drawn about efficacy.

/D with Radiationtudies have used various forms of radiation therapy. Thearliest experience with combined therapy for MPM was re-orted by McCormack and coworkers, at Memorial Sloan-ettering Cancer Center (MSKCC).9 The combination of P/Dith external radiation and systemic chemotherapy in 18atients with epithelial mesothelioma produced a medianurvival of 16 months. In the subsequent 33 patients, brachy-herapy was added and the median survival was 21 months.

In another study at MSKCC, brachytherapy was used inatients following P/D who had gross residual disease fol-

owed by postoperative external beam radiation therapy (me-ian dose of 4200 cGy). Local failure or disease progressionccurred in 63% of patients and median survival was 13onths. Alberts and coworkers evaluated 262 patients withPM, 26 of whom had P/D followed by radiation and che-
otherapy.10 The median survival for the whole group was M
.6 months and for the subset undergoing surgery was 10.9onths, which was not a statistically significantly difference.A Finnish study comprising 100 patients evaluated five

ifferent adjuvant radiation schedules and chemotherapyegimens following pleurectomy.11 The median survival wasmonths and the 2-year survival was 20%. They found no

ifference among the groups.In a more recent study, Lee and colleagues from University

f California, San Francisco reported their experience with2 patient who had undergone P/D with intraoperative ra-iotherapy followed by external beam radiation.12 Some pa-ients received chemotherapy as well. The median survival ofhe 26 patients who underwent the planned treatment was8.1 months. Not included in the analysis are the three pa-ients who had unresectable disease, one patient with recur-ent disease, and two patients who had early postoperativeeaths.In patients deemed unfit for EPP who get P/D at MSKCC,

ur current practice is to give adjuvant external beam radia-ion therapy.

/D with Intrapleuralnd/or Systemic Chemotherapyusch and colleagues from MSKCC evaluated P/D followedy intrapleural cisplatin and mitomycin followed by systemicisplatin and mitomycin given 3 to 5 weeks postopera-ively.13 There were 28 patients who underwent P/D andeceived intrapleural chemotherapy. There was one postop-rative death and two patients who developed grade 4 neph-otoxicity. The median survival was 18 months and signifi-ant morbidity was present in 53% of patients. Local failureas high with 16 local relapses in 27 patients. The authorsere concerned about the potential for serious toxicity.Rice and coworkers studied 19 patients who had EPP (n �

0) or P/D (n � 9) followed by intrapleural administration ofisplatin and mitomycin in patients with stage I MPM.14 Theedian survival was 13 months and the treatment-relatedortality was 5%.A group from UCLA reported their results of 15 patients

ho underwent P/D followed by intrapleural cisplatin andytarabine.15 The median survival was 11.5 months with noreatment-related mortality. A similar study was reported byn Italian group who added systemic chemotherapy to theame regimen of P/D and intrapleural chemotherapy.16 Their0 patients also had an 11.5-month median survival.A group from Turkey reported on 20 patients who had P/D

ollowed by systemic chemotherapy consisting of cisplatin,itomycin, and �-interferon immunotherapy.17 The median

urvival was 12 months and the regimen was well tolerated.In a more recent study, Ceresoli and colleagues from Italy

etrospectively reviewed their experience with MPM andoted that the 16 patients that had P/D followed by chemo-herapy did better than patients who received P/D or chemo-herapy alone.18 The median survivals were 14 months in theombined treatment group, 12 months in the surgery aloneroup, and 8 months in the chemotherapy alone group. Innivariate analysis treatment modality had independentrognostic value.The search for effective therapies to achieve local control in
PM has sparked interest in a number of areas. Hyperther-

maMad

mpGttga

rlrsa

firo

PS(pactowcv

pePEgM1tms

CTcscopacpn

ecpqe

R

1

1

1

1

1

1

1

1

1

1

2


ia has been investigated in combination with surgery. Carrynd coworkers reported the results of three patients withPM who were given hyperthermic intrapleural mitomycin

t 42.6°C following P/D for 60 minutes.19 The technique waseemed safe.In a similar design, Ratto and coworkers gave hyperther-ic cisplatin (41.5°C) for 60 minutes following P/D (threeatients) or EPP (four patients).20 Patients also received 55y to chest wall incisions. There was no death or toxicity and

he treatment was well tolerated. An interesting finding washat systemic cisplatin levels were significantly higher in theroup that had P/D, indicating that the remaining lung playsn important role in the absorption of intrapleural cisplatin.

A group from the Netherlands studied the use of intrapleu-al hyperthermic (40 to 41°C) cisplatin and doxorubicin fol-owing P/D.21 There was considerable toxicity with morbidityeported in 47% of patients. The 11 patients had a medianurvival of 8 months. This group used the same protocol fordvanced thymoma patients.

In a dose escalation study, Sugarbaker and colleagues per-ormed P/D on 44 patients followed by intraperitoneal andpsilateral hemithoracic lavage with cisplatin at 42°C.22 Theyeported postoperative mortality of 11% and median survivalf 9 months.

/D and Photodynamic Therapyeveral studies evaluated the use of photodynamic therapyPDT), a new modality used to enhance local control.23,24 Ahotosensitizer is administered systemically and then targetreas are illuminated with laser to affect cell kill. Moskal andoworkers from Roswell Park reported their series of 40 pa-ients who had been treated with EPP (n � 7), P/D (n � 28),r P/D with lobectomy (n � 5) followed by PDT.24 Mortalityas 6.5%, with two of the deaths in the EPP group. Serious

omplications arose in 48.3% of patients. The median sur-ival was 15 months.

Pass and colleagues at the National Institutes of Healtherformed a randomized study of surgical resection, postop-rative cisplatin, interferon, and tamoxifen with or withoutDT.23 Twenty-five patients received PDT (11 P/D and 14PP) and 23 patients did not (12 P/D and 11 EPP). Theroups were similar and no survival difference was noted.edian survivals in the PDT group and non-PDT group were

4.4 and 14.1 months, respectively. The conclusion was thathere was no value of first-generation PDT when added toultimodality therapy. Further studies with newer photo-

ensitizers and increasing light doses are ongoing.

onclusionshe role of surgery in the management of MPM remainsontroversial. The range of goals of surgery include diagno-is, palliation of symptoms, debulking of tumor, and possiblyure. All these goals have been cited at one time or another byne group of surgeons or another as the main focus of theirarticular surgical intervention. The major approaches in thermamentarium of the mesothelioma surgeon are thoracos-opy for biopsy and pleurodesis, partial pleurectomy, radicalleurectomy and decortication, and extrapleural pneumo-
ectomy. With no set standards of care or overwhelming 2
vidence to guide the thoracic surgeon, a fair amount oflinical judgment and a frank discussion of goals with theatient and other members of the health care team are re-uired to formulate a comprehensive treatment plan. How-ver, it is clear that a multimodality approach is required.

eferences1. Wagner JC, Sleggs CA, Marchand P: Diffuse pleural mesothelioma and

asbestos exposure in the North Western Cape Province. Br J In Med17:260-271, 1960

2. Butchart EG, Ashcroft T, Barnsley WC, et al: Pleuropneumonectomy inthe management of diffuse malignant mesothelioma of the pleura: ex-perience with 29 patients. Thorax 31:15-24, 1976

3. Sugarbaker DJ, Jaklitsch MT, Bueno R, et al: Prevention, early detec-tion, and management of complications after 328 consecutive extra-pleural pneumonectomies. J Thor CV Surg 128:138-145, 2004

4. Heelan RT, Rusch VW, Begg CB, et al: Staging of malignant pleuralmesothelioma: comparison of CT and MR imaging. AJR Am J Roentge-nol 172:1039-1047, 1999

5. Benard F, Sterman D, Smith RJ, et al: Metabolic imaging of malignantpleural mesothelioma with fluorodeoxyglucose positron emission to-mography. Chest 114:713-722, 1998

6. Flores RM, Akhurst T, Gonen M, et al: Positron emission tomographydefines metastatic disease but not locoregional disease in patients withmalignant pleural mesothelioma. J Thorac Cardiovasc Surg 126:11-15,2003

7. Flores RM, Akhurst T, Gonen M, et al: FDG-PET predicts survival inpatients with malignant pleural mesothelioma. Proc Am Soc Clin Oncol22:620, 2003 (abstract)

8. Rusch VW: Pleurectomy/decortication in the setting of multimodalitytreatment for diffuse malignant pleural mesothelioma. Semin ThoracCardiovasc Surg 9:367-372, 1997

9. McCormack PM, Nagasaki F, Hilaris BS, et al: Surgical treatment ofpleural mesothelioma. Thorac Cardiovasc Surg 84:834-842, 1982

0. Alberts AS, Falkson G, Goedhals L, et al: Malignant pleural mesotheli-oma: a disease unaffected by current therapeutic maneuvers. J ClinOncol 6:527-535, 1988

1. Mattson K, Holsti LR, Tammilehto L, et al: Multimodality treatmentprograms for malignant pleural mesothelioma using high-dose hemi-thorax irradiation. Int J Radiat Oncol Biol Phys 24:643-650, 1992

2. Lee TT, Everett DL, Shu HK et al: Radical pleurectomy/decorticationand intra-operative radiotherapy followed by conformal radiation withor without chemotherapy for malignant pleural mesothelioma. J Tho-rac Cardiovasc Surg 124:1074-1077, 2002

3. Rusch VW, Saltz L, Venkatraman E, et al: A phase II trial of pleurec-tomy/decortication followed by intrapleural and systemic chemother-apy for malignant pleural mesothelioma. J Clin Oncol 12:1156-1163,1994

4. Rice TW, Adelstein DJ, Kirby TJ, et al: Aggressive multimodality ther-apy for malignant pleural mesothelioma. Ann Thorac Surg 58:24-29,1994

5. Lee JD, Perez S, Wang HJ, et al: Intrapleural chemotherapy for patientswith incompletely resected malignant mesothelioma: the UCLA expe-rience. J Surg Oncol 60:262-267, 1995

6. Colleoni M, Sartori F, Calabro F, et al: Surgery followed by intracavitaryplus systemic chemotherapy in malignant pleural mesothelioma. Tu-mori 82:53-56, 1996

7. Hastürk S, Tastepe I, Unlu M, et al: Combined chemotherapy in pleu-rectomized malignant pleural mesothelioma patients. J Chemother8:159-164, 1996

8. Cresoli GL, Locati L, Ferreri AJ, et al: Therapeutic outcome according tohistologic subtype in 121 patients with malignant pleural mesotheli-oma. Lung Cancer 34:279-287, 2001

9. Carry PY, Brachet A, Gilly FN, et al: A new device for the treatment ofpleural malignancies: intrapleural chemohyperthermia preliminary re-port. Oncology 50:348-352, 1993

0. Ratto GB, Civalleri D, Esposito M, et al: Pleural space perfusion withcisplatin in the multimodality treatment of malignant mesothelioma: afeasibility and pharmacokinetic study. Thorac Cardiovasc Surg 117:759-765, 1999

1. de Bree E, van Ruth S, Baas P, et al: Cytoreductive surgery and intra-

2

2

2


operative hyperthermic intrathoracic chemotherapy in patients withmalignant pleural mesothelioma or pleural metastases of thymoma.Chest 121:480-487, 2002

2. Sugarbaker D, Richards WG, Zellos LS, et al: Feasibility of pleurectomyand intraoperative bicavitary hyperthermic cisplatin lavage for me-sothelioma: a phase I-II study. Proc Am Soc Clin Oncol 22:620, 2003
(abstract)
3. Pass HI, Temeck BK, Kranda K, et al: Phase III randomized trial ofsurgery with or without intraoperative photodynamic therapy andpostoperative immunochemotherapy for malignant pleural mesotheli-oma. Ann Surg Oncol 4:628-633, 1997

4. Moskal TL, Dougherty TJ, Urschel JD, et al: Operation and photody-namic therapy for pleural mesothelioma: 6-year follow-up. Ann Thorac
Surg 66:1128-1133, 1998

Treatment of Malignant Pleural Mesothelioma: Pleurectomy with Adjuvant Therapy

Documents

Transcript of Treatment of Malignant Pleural Mesothelioma: Pleurectomy with Adjuvant Therapy