Methods: All patients with biopsy proven MPM who underwent EPP or P/D at three institutions were identified. Survival and prognostic factors were analyzed by the Kaplan-Meier method, log-rank test, and Cox proportional hazards analysis. A p value of less than 0.05 was considered statistically significant.

Results: From 1990-2005, 663 consecutive patients underwent surgical resection. Median age was 65 years (26-93 range), 538 men and 125 women. Operative mortality was 7% for EPP (n=27/385) and 4% for P/D (n=13/278). Kaplan-Meier analysis demonstrated significant differences for AJCC stages 1-4 (p<.001), epithelioid versus non-epithelioid histology (p<.001), and EPP versus P/D (p< .001). Stratified analysis revealed that there was no difference in median survival for Stage I and II patients having P/D (n=98; 23 months) vs EPP (n=96; 19 months, p=0.07). A Cox proportional hazards analysis demonstrated a HR of 1.2 for EPP (p=0.06) controlling for stage (HR =1.8, p<.001) and histology (HR =1.5, p<.001). Analysis of patterns of recurrence is ongoing.

Conclusion: P/D demonstrated better overall survival than EPP. However, the surgical procedure is inherently stage dependent and presently driven by surgeon bias. Advanced stage favors EPP for resection of all gross disease, but P/D appears to be acceptable in early stages where resection of all gross disease is possible.