MALİGN PLEVRAL MEZOTELYOMADA KOMBİNE (MULTİMODALİTE) TEDAVİ

Year 2003, Volume: 17 Issue: 2, 19 - 28, 01.10.2003

Alpay Örki Murat Keleş Şenol Ürek Hakan Kıral Altuğ Koşar Kemal Temürtürkan Canan Ş. Dudu Bülent Arman

Abstract

Malign plevral mezotelyoma plevranın primer tümörü olup oldukça agresif seyreden ve tedavi edilmeyen olgularda ortalama sağ kalımın 4-8 ay gibi kısa olduğu bir hastalıktır. Tek başına hiçbir tedavi seçeneğinin sağ kalımı uzatmadığı bilinen malign plevral mezotelyomada en sık kabul gören tedavi yaklaşımı multimodalite tedavisidir. Merkezimizde 1996-2002 yılları arasında opere ettiğimiz ve adjuvan kemo-radyoterapi uyguladığımız epitelyal tip Evre I-II 26 hastayı çalışmamıza aldık. Sekizi kadın, 18 erkek olan hastalarımızın yaş ortalaması 49.4 (30-65) idi. Hastalık 15 olguda sağ, 11 olguda sol hemitoraksta yerleşim göstermekteydi. On dört (%53.8) hastada asbest teması mevcuttu. En sık karşılaşılan semptomlar nefes darlığı (%73) ve göğüs ağrısı (%65) idi. Tüm hastalarımıza tanı ve evreleme amaçlı videoyard ımlı torakoskopik cerrahi uygulandı. Hastalar International Mesothelioma Interest Group (IMIG) evreleme sistemine göre evrelendi. Buna göre Evre Ib ve II'deki 11 hastaya ekstraplevral pnömonektomi (Grup I), Evre Ia ve Ib deki 15 olguya plörektomi/dekortikasyon (Grup II) yapıldı. Çalışmamızın mortalitesi %3.8 (1/26) idi ve yalnız bir hastada majör komplikasyon (bronkoplevral fistül) gözlendi. Postoperatif dönemde adjuvan kemoradyoterapi uygulandı. Kemoterapötik ajan olarak Epirubisin 80 mg/m2 + Siklofosfamid 600 mg/m2 tek gün 6 kür olarak kullanıldı. Radyote-rapi dozu ise yapılan ameliyata göre ayarlandı. Grup I'de ortalama sağ kalım 24 ay, 2 yıllık sağ kalım %60, 5 yılık sağ kalım %40; Grup II'de ortalama sağ kalım 19 ay, 2 yıllık sağ kalım %46 ve 5 yıllık sağ kalım %33 olarak hesaplandı. Buna göre ortalama, 2 ve 5 yıllık sağ kalımlar açısından gruplar arasında istatistiksel olarak anlamlı fark bulunmadı (p=0.65). Sonuç olarak cerrahi, kemoterapi ve radyoterapiden ibaret olan multimodalite tedavi hastalığın lokal kontrolünde ve sağ kalımın uzatılmasında en etkili tedavi yöntemi olmaktadır.

Keywords

Malign plevral mezotelyoma, multimodalite tedavi

MULTIMODALITY THERAPY FOR MALIGNANT PLEURAL MESOTHELIOMA

Abstract

Malignant pleural mesothelioma is primary tumor of the pleura which has agressive behavior and poor prognosis with a median survival ranging from 4 to 8 months for untreated cases. Single modality treatment for malignant pleural mesothelioma, whether chemotherapy, radiation therapy, or surgery is not able to prolong life by more than several months. For that reason, multimodality therapy has been currently prefered in many clinics. This study included 26 patients with epithelial type of mesothelioma (Stage-I-II) which were operated in our center and received adjuvant chemo-radiotherapy between 1996 and 2002. There were 18 men and 8 women with a mean age 49.4 years (ranged from 30 to 65). The disease was on the right side in 15 cases, and left side in 11. The asbestos exposure was present in 14 (53.8%) patients. The most common symptoms were dyspnea (73%), chest pain (65%). All patients underwent video-asisted thoracoscopic surgery (VATS) for diagnosis and staging. The International Mesothelioma Interest Group (IMIG) staging system was used to determine T and N status and tumor stage in all of our patients. Extrapleural pneumonectomy (EPP) (Group I) was performed in 11 patients with stage Ib and II mesothelioma and Pleurectomy/Decortication (P/D) (Group II) was performed in 15 patients in stage Ia and Ib. The mortality rate was %3.8 (1/26). The major complication (Broncopleural fistula) occured only one patient in Group I. The median survival was 24 months; 2-year and 5-year survival were 60% and 40% respectively in Group I. The median survival was 19 months 2-year and 5-year survival were 46% and 35% respectively for Group II. There was no significant differance statistificaly Group I and Group II in regarding to median survival, 2-year and 5-year survival (p=0.65) In conclusion, multimodality therapy including surgery, chemotherapy, radiation therapy is the most effective treatment in the locoregional control of disease and to improve survival rates of malignant pleural mesothelioma.

Keywords

Malignant pleural mesothelioma, multimodality therapy

References

• 1. Valerie W. Rush. Diffüse Malignant Mesothelioma. In Shields TW, General Thoracic Surgery, Fifth Edition, Lippincott Williams & Wilkins Philedelphia2000; 767-82, cp; 65.
• 2. Metintafl M. Primer Plevra Maligniteleri. Solunum 2002; 4(1): 49-64.
• 3. Kelefl M, Tezel Ç. Diffuz Malign Mezotelyoma. Heybeliada T›p Bülteni 2001; 7(1): 42-6.
• 4. Örki A, Kelefl M, Koflar A, Aydemir SC, Dudu fiC, Ersev A.A, Arman B. Plevral efüzyonun Tan›s›nda Cope/VATS Biyopsisi. Heybeliada T›p Bülteni 2001; 7(3): 7-10.
• 5. Butchart EG. Contemporary Management of Malignant Pleural Mesthelioma. The Oncologist 1999; 4: 488-500.
• 6. fienol C, Çelik M, Babao¤lu A, Halezero¤lu S, Uysal A, K›ral H, Kurutepe M, Sayg› A, Arman B, Öztek ‹. Plevral Mezotelyomada Tan› ve Tedavi Yaklafl›mlar›. Heybeliada T›p Bülteni 1995; 1(3): 33-41.
• 7. K›ral H, fienol C, Çelik M, Uysal A, Tekin A, Tekin A, Yalç›n Z, Arman B. Diffüz Malign Plevral Mezotelyomada Tan› ve Tedavi sonuçlar›m›z. Solunum Hastal›klar› 1997; 8(2): 185-92.
• 8. Bar›fl Y‹. Asbestos and erionite related chest diseases. Ankara Semih osfet matbac›l›k, 1987: 8-139.
• 9. British Thoracic Society Standarts of Care Committee. Statement on Malignant Mesothelioma in the United Kingdom. Thorax 2001; 56: 250-65.
• 10. Celik M, Halezeroglu S, Senol C, Keles M, Yalcin Z, Urek S, Kiral H, Arman B. Video-asistedd thoracoscopic sugery: experience with 341 cases. Eur J Cardiothorac Surg 1998;14 : 113-6.
• 11. Butchart EG, Ashcroft T, Barnsley WC, Holden MP. Pleuropneumonectomy in the Management of Diffuse Malignant Mesothelioma of the Pleura. Experince with 29 Patients. Thorax 1976; 31: 15-24.
• 12. Rush VW, Venkatraman E. The Importance of Surgical Staging in the treatment of Malignant Pleural mesothelioma. J Thorac Cardiovasc Surg 1996; 111: 815-26.
• 13. From the Internationale mesothelioma Interest Gruoup. A Proposed New International TNM Staging system for Malignant Pleural Mesothelioma. Chest 1995; 108: 1122-8.
• 14. Shields TW: Anathomy of the Pleura. General Thoracic Surgery Lippinkott Williams & Wilkins Philedelphia 2000 cp 54 667-70.
• 15. Sugarbaker DJ, Flores RM, Jaklitsch MT, Richards WG, Strauss GM, Corson JM, Decamp MM, Swanson SJ, Bueno R, Lukanich JM, Baldini EH, Mentzer SJ. Resection Margins, Extrapleural Nodal Status and Cell Type Determine Postoperative Long-Time Survival In Trimodality Therapy of Malign Pleural Mesothelioma: Results In 183 Patients. J Thorac Cardiovasc Surg 1999; 117: 54-65.
• 16. Ratto GB, Civalleri D, Esposito M, Esposito M, Spessa E, Alloisio A, De Cian F, Vannozi MO. Pleural Space Perfüsion with Cisplatin in the Multimodality Treatment of Malignant Mesothelioma: A Feasibility and Pharmacokinetic Study. J Thorac Cardiovasc Surg 1999; 117: 759-65.
• 17. De Bree E, Ruth SV, Bass P, Rutgers EJ, Zondwijk NV, Witkamp AJ, Zoetmulder FAN. Cytoreductive Surgery and Intraoperative Hyperthermic Intrathoracic Chemotherapy in Patients with Malignant Pleural Mesothelioma or Pleural Metastaes of Thymoma. Chest 2002; 121: 480-7.
• 18. Pass HI, Robinson BW, Testa JR, Carbone M. Emerging Translatinal Therapies for Mespthelioma. Chest 1999; 116: 455-60.