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. 2013 May 8;17(2):407–412. doi: 10.1093/icvts/ivt153

Table 1:

Best evidence papers

Author, date & country, journal Study type
(level of evidence)		 Patient group Outcomes Key results
 Comments
Okamoto et al. (2012) Japan [2];Eur J Cardiothorac Surg

Retrospective
single-centre case series (level 3)		 Between 1990 and 2007, 73 patients with pleural involvement were evaluated


Subgroups
MPE (n = 32)
MPN (n = 41)
Distant metastases (M1b) (n = 25)

Surgery
Lobectomy (n = 73)
Pneumonectomy (n = 5)
Bilobectomy (n = 11)
Partial resection resection (n = 9)

Other treatment
Intrapleural chemotherapy: 50%
Postoperative systemic chemotherapy (mitomycin-C or cisplatin): 33%		 MST (months) Variables n MST P M1a resected patients had better survival than M1b patients

Among M1a patients, surgery may be indicated for MPE patients with N0–1 status
M1a/M1b
N0–1/N2–3
MPE-N0–1/MPE-N2–3
MPN-N0–1/MPN-N2–3
Others/Pn		 73/25
7/39
14/18

20/21

70/3		 25.9/8.7
37.7/24.4
75.4/24.4

33.7/24.1

26.1/12.8		 0.014
0.004
0.011

0.15

0.001
Ichinose et al, (2001) Japan [3];Surgery Today

Retrospective
multicentre study
(level 3)		 Between January 1985 and December 1994, 227 patients were evaluated

Subgroups
MPE (n = 55)
MPN (n = 89)
MPE + MPN (n = 83)

Surgery
Resection (R)
Lobectomy (n = 139)
Pneumonectomy: (n = 29) Limited resection (n = 25)
Exploratory thoracotomy (ET) (n = 34)

Other treatment
Intrapleural chemotherapy (cisplatin; adriamycin; mitomycin): 44%
Intrapleural sclerosing agent: 3% Postoperative chemotherapy (platinum based combination): 47% Radiotherapy with or without chemotherapy: 9%

 YST (%)

 Variables n 3-YST 5-YST P Surgery is associated with longer survival in case of histology of adenocarcinoma
N0 status and freedom from macroscopical residual tumour
R/ET
Ad/oth.
pN0/1/2
MRT−/MRS+		 193/34
178/49
58/31/97
155/61		 29/11
29/16
47/35/14
31/13
 15/0
14.5/9
28/15/5
18/6
 0.04
0.004
<0.0001
0.001
Fukuse et al. (2001) Japan [4]; Lung Cancer

Retrospective
single-centre case series
(level 3)		 From January 1981 to December 1997, 49 patients were evaluated Operative mortality 1 patient (2%) Surgery may be indicated in patients with T1-2 primary tumour and with MPE only

Subgroups
MPE (n = 16)
MPN (n = 17)
MPE + MPN (n = 16)



Surgery
Complete resection (CR): Lobectomy with/or without Pl (n = 27)
Pleuropneumonectomy (n = 5)
Partial resection (PR) (n = 7)
Exploratory thoracotomy (ET) (n = 10)		 MST (months) Variables n MST P
CR/PR/ET
MPE/MPN/
MPE + MPN
T1/2/3
pN0/N2

 32/7/10
16/17/16

9/28/12
–

 37.9/23.2/6.2
58.8/10a/19.3b

37/15c/9.9d
23/10.4		 –
a0.0001; b0.019

c0.0004; d0.011
0.09

Other treatment
Intrapleural chemotherapy (cisplatin; adriamycin; mitomycin; alone or in combination): 100% Postoperative chemotherapy: 100% (cisplatin in 41%)
Adjuvant radiotherapy: 6%		 YST (%) All patients MPE MPN MPE + MPN
3-YST
5-YST		 26.7
15.7		 60
45		 6.3
0		 9.1
0
Shiba et al. (2001) Japan [5];Ann Thorac Surg

Retrospective
single-centre case series
(level 3)		 From 1985 to 1995, 65 patients were valuated

Subgroups
MPE or D0 (n = 25)
MPN with/or without MPE or D1 (n = 40)

Surgery
Lobectomy (L) (n = 55)
Partial resection (PR) or exploratory thoracotomy (ET) (n = 10)
In all specimens Ki-67, a tumour proliferative marker was evaluated

Other treatment
Intrapleural chemotherapy (mytomicin-C): 100%		 YST (%) Variables n 5-YST P Surgery appears to be beneficial in patients with N0 status and low Ki-67 index
L/PR + ET
D0/D1
Ad/oth.
N0/N1-2
Ki-67low/Ki-67high		 55/10
25/40
58/7
11/46
21/36		 14/0
22.9/8.9
13.2/0
46.7/5.8
28.6/4.1		 –
0.45
0.02
0.01
<0.0001
Kodama et al. (1993) Japan [6]; Cancer

Retrospective
single-centre case series
(level 3)		 From April 1985 to December 1991, 31 patients were valuated

Subgroups
MPE: 6
MPN with or without MPE: 25 (7 clinically diagnosed)

Surgery
Pleuropneumonectomy (n = 5)
Pneumonectomy (n = 3)
Lobectomy (n = 18)
Segmentectomy or wedge (n = 5)

Other treatment
Intrathoracic chemotherapy (cisplatin) with radio frequency hyperthermia: 100%		 MST (months)
YST (%)		 Variables n MST 3-YST 5-YST P Surgery may be indicated in patients with N0 status
N0–1/N2 14/17 43/16 68.4/22.7 48.7/0 0.01
Shigemura et al. (2003) Japan [7]; Interact CardioVasc Thorac Surg

Retrospective
single-centre case series
(level 3)		 Five patients with MPE + MPN were evaluated
Four were clinically diagnosed		 Operative mortality


MST (months)		 0% Multimodality treatment seems to be effective for radical local tumour control in very selected cases

Surgery
Panpleuropneumonectomy (n = 5)		 19

Other treatment
Intrapleural hyperthermic chemotherapy before and after operation (cisplatin): 100%
Postoperative systemic chemotherapy: 100%		 The poorest survival was 8 months (T4N2M0) and the longest was 32 months (T4N0M0)
Kimura et al. (2010) Japan [8];
Interact CardioVasc Thorac Surg

Retrospective
single-centre non-consecutive case series
(level 3)		 From May 2001 to July 2005 and from October 2006 to November 2008, 19 patients with pathologically MPE with/or without MPN were evaluated Operative mortality 0% Intrapleural hyperthermic therapy alone or with chemotherapy might be beneficial in the prevention of pleural effusion

Subgroups
Group A (n = 7): Intraoperative intrathoracic hyperthermotherapy

Group B (n = 5): Intraoperative intrathoracic hyperthermo-chemotherapy

Group C (n = 7): no additional therapy
Each patient received chemotherapy after surgery (different regimen)

Surgery
Lobectomy (n = 10)
Segmentectomy or wedge (n = 6)
Probe thoracotomy (n = 3) all classified in Group A		 MST (months)
Recurrence of pleural effusion (RPE) (%)		 Variables Group A Group B Group C P
MTS
RPE		 19.4
0		 41
20		 25
57*		 NS
*0.02
Sawabata et al. (2002) Japan [9];
Ann Thorac Surg

Retrospective
single-centre case series
(level 3)		 Between 1980 and 1994, 43 patients were evaluated

Subgroups
MPE (n = 22)
MPN (n = 21)

Surgery
Complete resection (CR) (n = 11)
Incomplete resection (IR) (n = 14)
Exploratory thoracotomy (ET) (n = 18)

No chemotherapy		 MST (months)
YST (%)		 Variables n MST 5-YST P Surgery is not beneficial
CR/IR/ET 11/14/18 13/34/17 9/10/0 –

aMPN vs MPE.

bMPE + MPN vs MPE.

cT2 vs T1.

dT3 vs T1.

*Group C vs Group A.