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• W2012124480 abstract "To the EditorWe read with great interest the article by Schouwink et al (October 2001)1Schouwink H Rutgers ET Van Der Sijp J et al.Intraoperative photodynamic therapy after pleuropneumonectomy in patients with malignant pleural mesothelioma: dose finding and toxicity results.Chest. 2001; : 1167-1174Abstract Full Text Full Text PDF Scopus (77) Google Scholar about intraoperative photodynamic therapy after pleuropneumonectomy for the treatment of patients with pleural mesothelioma.In the series by Sugarbaker et al,2Sugarbaker DJ Flores RM Jaklitsch MT et al.Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: results in 183 patients.J Thorac Cardiovasc Surg. 1999; 117: 54-65Abstract Full Text Full Text PDF PubMed Scopus (809) Google Scholar pleuropneumonectomy has a low postoperative mortality rate (3.8%) and relatively satisfying long-term results. Their technique involves opening the pericardial cavity and resecting the diaphragm while preserving the peritoneum. However, mesothelioma is one of the most rapidly disseminating tumors. As recommended by Schouwink et al,1Schouwink H Rutgers ET Van Der Sijp J et al.Intraoperative photodynamic therapy after pleuropneumonectomy in patients with malignant pleural mesothelioma: dose finding and toxicity results.Chest. 2001; : 1167-1174Abstract Full Text Full Text PDF Scopus (77) Google Scholar it would seem preferable not to open the pericardium, as we were able to do in the five most recent pleuropneumonectomies that we have performed for the treatment of patients with mesothelioma. Similarly, it is often possible to leave diaphragmatic muscle and fibers in place in order to avoid tearing the peritoneum when detaching it. The high rate of peritoneal recurrences following pleuropneumonectomy reported by Baldini et al (26%)3Baldini EH Recht A Strauss GM et al.Patterns of failure after trimodality therapy for malignant pleural mesothelioma.Ann Thorac Surg. 1997; 63: 334-338Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar and Rusch et al (31%)4Rusch VW Rosenzweig K Venkatraman E et al.A phase II trial of surgical resection and adjuvant high-dose hemithoracic radiation for malignant pleural mesothelioma.Thorac Cardiovasc Surg. 2001; 122: 788-795Abstract Full Text Full Text PDF Scopus (421) Google Scholar may be due to seeding by transdiaphragmatic invasion before surgery or to peroperative tearing of the peritoneum or to secondary peritoneal necrosis.To be sure, adjunct local treatment is essential to prevent intracavitary recurrence, which is otherwise inescapable. Radiotherapy is effective in treating mesothelioma.5Boutin C Rey F Viallat JR Prevention of malignant seeding after invasive diagnostic procedures in patients with pleural mesothelioma.Chest. 1995; 7: 317-318Google Scholar However, the local recurrence rate remained high (35%) in a series of 49 patients who underwent surgery in Boston between 1987 and 1993.3Baldini EH Recht A Strauss GM et al.Patterns of failure after trimodality therapy for malignant pleural mesothelioma.Ann Thorac Surg. 1997; 63: 334-338Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar Radiation therapy, which was performed in only 35 of these patients, consisted of a median dose of 30.6 Gy to the hemithorax and a boost dose of 50 Gy to areas with gross residual disease or localized positive resection margins.3Baldini EH Recht A Strauss GM et al.Patterns of failure after trimodality therapy for malignant pleural mesothelioma.Ann Thorac Surg. 1997; 63: 334-338Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar Higher radiation doses of up to 54 Gy to the entire hemithorax appear to significantly reduce the local recurrence rate (13%) in the series reported by Rusch et al.4Rusch VW Rosenzweig K Venkatraman E et al.A phase II trial of surgical resection and adjuvant high-dose hemithoracic radiation for malignant pleural mesothelioma.Thorac Cardiovasc Surg. 2001; 122: 788-795Abstract Full Text Full Text PDF Scopus (421) Google Scholar To decrease the liver and intestinal toxicity associated with high radiation doses to the diaphragmatic sinus, the abdominal organs may be lowered by reconstructing a taut prosthetic diaphragm during surgery. However, radiation doses of > 50 Gy to the heart remain potentially toxic, in particular doses delivered to the left side of the heart, and intraoperative photodynamic therapy, as suggested by Schouwink et al,1Schouwink H Rutgers ET Van Der Sijp J et al.Intraoperative photodynamic therapy after pleuropneumonectomy in patients with malignant pleural mesothelioma: dose finding and toxicity results.Chest. 2001; : 1167-1174Abstract Full Text Full Text PDF Scopus (77) Google Scholar seems to be an interesting alternative.I was fortunate to be invited to Amsterdam and to obtain light dosimetry equipment there. For large pleural cavities, the potential complications associated with the technique are due to a narrow anatomic zone that includes in particular the esophagus, the bronchial and vascular stumps, and the myocardium. These anatomic structures are located very close to the light source that illuminates the cavity during intraoperative photodynamic therapy. We have studied the fluence (at the wavelengths that react with meso-tetra[hydroxyphenyl] chlorine) emitted by the surgical theater lights during resection. Although our calculations are approximate, fluence may be as high as 5 J/cm2. We therefore decided to shield the esophagus, the bronchial and vascular stumps, and the pericardium. Conversely, the most difficult zone to illuminate was the pleural cul de sac. The diaphragm is lowered by running taut polyglactic acid sutures from one edge to the other, before illumination. Three patients received 0.15 mg/kg meso-tetra(hydroxyphenyl) chlorine and were operated on using these modified techniques while the cavity was illuminated with a 652-nm laser light and a fluence of 10 J/cm2, except for the shielded zone. The large quantity of fluid drained postoperatively gave an indication of the effect of phototherapy on the pleural cavity walls. Slowing of esophageal motor activity was observed in all three cases.Postoperative electrotherapy was performed in the first two patients on the thoracotomy scar and the pleural cul de sac. No recurrence was observed after 2½ years in one patient (as determined by follow-up CT scan) and after 26 months in the other patient (as determined by follow-up CT scan and negative thoracoscopy findings at 12 months). The third patient developed an infection of the chest wall, which was complicated by an infection of the pneumonectomy cavity. Radiation therapy was impossible to perform. Thoracostomy was performed 9 months later and revealed a late esophageal fistula involving the upper one third of the esophagus (in an unshielded zone). The fistula was closed with a muscle flap. No recurrence was observed in the pleural cavity. Unfortunately, the patient eventually died.In our limited experience, high-dose preoperative phototherapy therefore appears capable of destroying tumor residues but seems to require major precautions, such as shielding of the incision and the mediastinal organs. Consequently, its place among other techniques seems limited if future series confirm the low local recurrence rate reported by the New York team with the adjunction of high-dose hemithoracic radiation therapy and if the toxicity associated with radiation therapy remains low. To the EditorWe read with great interest the article by Schouwink et al (October 2001)1Schouwink H Rutgers ET Van Der Sijp J et al.Intraoperative photodynamic therapy after pleuropneumonectomy in patients with malignant pleural mesothelioma: dose finding and toxicity results.Chest. 2001; : 1167-1174Abstract Full Text Full Text PDF Scopus (77) Google Scholar about intraoperative photodynamic therapy after pleuropneumonectomy for the treatment of patients with pleural mesothelioma.In the series by Sugarbaker et al,2Sugarbaker DJ Flores RM Jaklitsch MT et al.Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: results in 183 patients.J Thorac Cardiovasc Surg. 1999; 117: 54-65Abstract Full Text Full Text PDF PubMed Scopus (809) Google Scholar pleuropneumonectomy has a low postoperative mortality rate (3.8%) and relatively satisfying long-term results. Their technique involves opening the pericardial cavity and resecting the diaphragm while preserving the peritoneum. However, mesothelioma is one of the most rapidly disseminating tumors. As recommended by Schouwink et al,1Schouwink H Rutgers ET Van Der Sijp J et al.Intraoperative photodynamic therapy after pleuropneumonectomy in patients with malignant pleural mesothelioma: dose finding and toxicity results.Chest. 2001; : 1167-1174Abstract Full Text Full Text PDF Scopus (77) Google Scholar it would seem preferable not to open the pericardium, as we were able to do in the five most recent pleuropneumonectomies that we have performed for the treatment of patients with mesothelioma. Similarly, it is often possible to leave diaphragmatic muscle and fibers in place in order to avoid tearing the peritoneum when detaching it. The high rate of peritoneal recurrences following pleuropneumonectomy reported by Baldini et al (26%)3Baldini EH Recht A Strauss GM et al.Patterns of failure after trimodality therapy for malignant pleural mesothelioma.Ann Thorac Surg. 1997; 63: 334-338Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar and Rusch et al (31%)4Rusch VW Rosenzweig K Venkatraman E et al.A phase II trial of surgical resection and adjuvant high-dose hemithoracic radiation for malignant pleural mesothelioma.Thorac Cardiovasc Surg. 2001; 122: 788-795Abstract Full Text Full Text PDF Scopus (421) Google Scholar may be due to seeding by transdiaphragmatic invasion before surgery or to peroperative tearing of the peritoneum or to secondary peritoneal necrosis.To be sure, adjunct local treatment is essential to prevent intracavitary recurrence, which is otherwise inescapable. Radiotherapy is effective in treating mesothelioma.5Boutin C Rey F Viallat JR Prevention of malignant seeding after invasive diagnostic procedures in patients with pleural mesothelioma.Chest. 1995; 7: 317-318Google Scholar However, the local recurrence rate remained high (35%) in a series of 49 patients who underwent surgery in Boston between 1987 and 1993.3Baldini EH Recht A Strauss GM et al.Patterns of failure after trimodality therapy for malignant pleural mesothelioma.Ann Thorac Surg. 1997; 63: 334-338Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar Radiation therapy, which was performed in only 35 of these patients, consisted of a median dose of 30.6 Gy to the hemithorax and a boost dose of 50 Gy to areas with gross residual disease or localized positive resection margins.3Baldini EH Recht A Strauss GM et al.Patterns of failure after trimodality therapy for malignant pleural mesothelioma.Ann Thorac Surg. 1997; 63: 334-338Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar Higher radiation doses of up to 54 Gy to the entire hemithorax appear to significantly reduce the local recurrence rate (13%) in the series reported by Rusch et al.4Rusch VW Rosenzweig K Venkatraman E et al.A phase II trial of surgical resection and adjuvant high-dose hemithoracic radiation for malignant pleural mesothelioma.Thorac Cardiovasc Surg. 2001; 122: 788-795Abstract Full Text Full Text PDF Scopus (421) Google Scholar To decrease the liver and intestinal toxicity associated with high radiation doses to the diaphragmatic sinus, the abdominal organs may be lowered by reconstructing a taut prosthetic diaphragm during surgery. However, radiation doses of > 50 Gy to the heart remain potentially toxic, in particular doses delivered to the left side of the heart, and intraoperative photodynamic therapy, as suggested by Schouwink et al,1Schouwink H Rutgers ET Van Der Sijp J et al.Intraoperative photodynamic therapy after pleuropneumonectomy in patients with malignant pleural mesothelioma: dose finding and toxicity results.Chest. 2001; : 1167-1174Abstract Full Text Full Text PDF Scopus (77) Google Scholar seems to be an interesting alternative.I was fortunate to be invited to Amsterdam and to obtain light dosimetry equipment there. For large pleural cavities, the potential complications associated with the technique are due to a narrow anatomic zone that includes in particular the esophagus, the bronchial and vascular stumps, and the myocardium. These anatomic structures are located very close to the light source that illuminates the cavity during intraoperative photodynamic therapy. We have studied the fluence (at the wavelengths that react with meso-tetra[hydroxyphenyl] chlorine) emitted by the surgical theater lights during resection. Although our calculations are approximate, fluence may be as high as 5 J/cm2. We therefore decided to shield the esophagus, the bronchial and vascular stumps, and the pericardium. Conversely, the most difficult zone to illuminate was the pleural cul de sac. The diaphragm is lowered by running taut polyglactic acid sutures from one edge to the other, before illumination. Three patients received 0.15 mg/kg meso-tetra(hydroxyphenyl) chlorine and were operated on using these modified techniques while the cavity was illuminated with a 652-nm laser light and a fluence of 10 J/cm2, except for the shielded zone. The large quantity of fluid drained postoperatively gave an indication of the effect of phototherapy on the pleural cavity walls. Slowing of esophageal motor activity was observed in all three cases.Postoperative electrotherapy was performed in the first two patients on the thoracotomy scar and the pleural cul de sac. No recurrence was observed after 2½ years in one patient (as determined by follow-up CT scan) and after 26 months in the other patient (as determined by follow-up CT scan and negative thoracoscopy findings at 12 months). The third patient developed an infection of the chest wall, which was complicated by an infection of the pneumonectomy cavity. Radiation therapy was impossible to perform. Thoracostomy was performed 9 months later and revealed a late esophageal fistula involving the upper one third of the esophagus (in an unshielded zone). The fistula was closed with a muscle flap. No recurrence was observed in the pleural cavity. Unfortunately, the patient eventually died.In our limited experience, high-dose preoperative phototherapy therefore appears capable of destroying tumor residues but seems to require major precautions, such as shielding of the incision and the mediastinal organs. Consequently, its place among other techniques seems limited if future series confirm the low local recurrence rate reported by the New York team with the adjunction of high-dose hemithoracic radiation therapy and if the toxicity associated with radiation therapy remains low. We read with great interest the article by Schouwink et al (October 2001)1Schouwink H Rutgers ET Van Der Sijp J et al.Intraoperative photodynamic therapy after pleuropneumonectomy in patients with malignant pleural mesothelioma: dose finding and toxicity results.Chest. 2001; : 1167-1174Abstract Full Text Full Text PDF Scopus (77) Google Scholar about intraoperative photodynamic therapy after pleuropneumonectomy for the treatment of patients with pleural mesothelioma. In the series by Sugarbaker et al,2Sugarbaker DJ Flores RM Jaklitsch MT et al.Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: results in 183 patients.J Thorac Cardiovasc Surg. 1999; 117: 54-65Abstract Full Text Full Text PDF PubMed Scopus (809) Google Scholar pleuropneumonectomy has a low postoperative mortality rate (3.8%) and relatively satisfying long-term results. Their technique involves opening the pericardial cavity and resecting the diaphragm while preserving the peritoneum. However, mesothelioma is one of the most rapidly disseminating tumors. As recommended by Schouwink et al,1Schouwink H Rutgers ET Van Der Sijp J et al.Intraoperative photodynamic therapy after pleuropneumonectomy in patients with malignant pleural mesothelioma: dose finding and toxicity results.Chest. 2001; : 1167-1174Abstract Full Text Full Text PDF Scopus (77) Google Scholar it would seem preferable not to open the pericardium, as we were able to do in the five most recent pleuropneumonectomies that we have performed for the treatment of patients with mesothelioma. Similarly, it is often possible to leave diaphragmatic muscle and fibers in place in order to avoid tearing the peritoneum when detaching it. The high rate of peritoneal recurrences following pleuropneumonectomy reported by Baldini et al (26%)3Baldini EH Recht A Strauss GM et al.Patterns of failure after trimodality therapy for malignant pleural mesothelioma.Ann Thorac Surg. 1997; 63: 334-338Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar and Rusch et al (31%)4Rusch VW Rosenzweig K Venkatraman E et al.A phase II trial of surgical resection and adjuvant high-dose hemithoracic radiation for malignant pleural mesothelioma.Thorac Cardiovasc Surg. 2001; 122: 788-795Abstract Full Text Full Text PDF Scopus (421) Google Scholar may be due to seeding by transdiaphragmatic invasion before surgery or to peroperative tearing of the peritoneum or to secondary peritoneal necrosis. To be sure, adjunct local treatment is essential to prevent intracavitary recurrence, which is otherwise inescapable. Radiotherapy is effective in treating mesothelioma.5Boutin C Rey F Viallat JR Prevention of malignant seeding after invasive diagnostic procedures in patients with pleural mesothelioma.Chest. 1995; 7: 317-318Google Scholar However, the local recurrence rate remained high (35%) in a series of 49 patients who underwent surgery in Boston between 1987 and 1993.3Baldini EH Recht A Strauss GM et al.Patterns of failure after trimodality therapy for malignant pleural mesothelioma.Ann Thorac Surg. 1997; 63: 334-338Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar Radiation therapy, which was performed in only 35 of these patients, consisted of a median dose of 30.6 Gy to the hemithorax and a boost dose of 50 Gy to areas with gross residual disease or localized positive resection margins.3Baldini EH Recht A Strauss GM et al.Patterns of failure after trimodality therapy for malignant pleural mesothelioma.Ann Thorac Surg. 1997; 63: 334-338Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar Higher radiation doses of up to 54 Gy to the entire hemithorax appear to significantly reduce the local recurrence rate (13%) in the series reported by Rusch et al.4Rusch VW Rosenzweig K Venkatraman E et al.A phase II trial of surgical resection and adjuvant high-dose hemithoracic radiation for malignant pleural mesothelioma.Thorac Cardiovasc Surg. 2001; 122: 788-795Abstract Full Text Full Text PDF Scopus (421) Google Scholar To decrease the liver and intestinal toxicity associated with high radiation doses to the diaphragmatic sinus, the abdominal organs may be lowered by reconstructing a taut prosthetic diaphragm during surgery. However, radiation doses of > 50 Gy to the heart remain potentially toxic, in particular doses delivered to the left side of the heart, and intraoperative photodynamic therapy, as suggested by Schouwink et al,1Schouwink H Rutgers ET Van Der Sijp J et al.Intraoperative photodynamic therapy after pleuropneumonectomy in patients with malignant pleural mesothelioma: dose finding and toxicity results.Chest. 2001; : 1167-1174Abstract Full Text Full Text PDF Scopus (77) Google Scholar seems to be an interesting alternative. I was fortunate to be invited to Amsterdam and to obtain light dosimetry equipment there. For large pleural cavities, the potential complications associated with the technique are due to a narrow anatomic zone that includes in particular the esophagus, the bronchial and vascular stumps, and the myocardium. These anatomic structures are located very close to the light source that illuminates the cavity during intraoperative photodynamic therapy. We have studied the fluence (at the wavelengths that react with meso-tetra[hydroxyphenyl] chlorine) emitted by the surgical theater lights during resection. Although our calculations are approximate, fluence may be as high as 5 J/cm2. We therefore decided to shield the esophagus, the bronchial and vascular stumps, and the pericardium. Conversely, the most difficult zone to illuminate was the pleural cul de sac. The diaphragm is lowered by running taut polyglactic acid sutures from one edge to the other, before illumination. Three patients received 0.15 mg/kg meso-tetra(hydroxyphenyl) chlorine and were operated on using these modified techniques while the cavity was illuminated with a 652-nm laser light and a fluence of 10 J/cm2, except for the shielded zone. The large quantity of fluid drained postoperatively gave an indication of the effect of phototherapy on the pleural cavity walls. Slowing of esophageal motor activity was observed in all three cases. Postoperative electrotherapy was performed in the first two patients on the thoracotomy scar and the pleural cul de sac. No recurrence was observed after 2½ years in one patient (as determined by follow-up CT scan) and after 26 months in the other patient (as determined by follow-up CT scan and negative thoracoscopy findings at 12 months). The third patient developed an infection of the chest wall, which was complicated by an infection of the pneumonectomy cavity. Radiation therapy was impossible to perform. Thoracostomy was performed 9 months later and revealed a late esophageal fistula involving the upper one third of the esophagus (in an unshielded zone). The fistula was closed with a muscle flap. No recurrence was observed in the pleural cavity. Unfortunately, the patient eventually died. In our limited experience, high-dose preoperative phototherapy therefore appears capable of destroying tumor residues but seems to require major precautions, such as shielding of the incision and the mediastinal organs. Consequently, its place among other techniques seems limited if future series confirm the low local recurrence rate reported by the New York team with the adjunction of high-dose hemithoracic radiation therapy and if the toxicity associated with radiation therapy remains low. Intraoperative Photodynamic Therapy After Pleuropneumonectomy for Malignant Pleural MesotheliomaCHESTVol. 122Issue 5PreviewWe thank Bonnette et al for the valuable comments on our study.1 In their reaction, they addressed the study of Sugarbaker et al,2 using a trimodality approach of extrapleural pneumonectomy combined with chemotherapy and radiotherapy and some aspects of the use of photodynamic therapy (PDT) after resection. In this study, the perioperative mortality is only 3.8% and the median survival is 19 months. Although the survival was not calculated on an intention-to-treat basis, results were better than what is generally achieved with the combination surgery and PDT. Full-Text PDF" @default.
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