End-of-life care: data supportive?

the cavity was illuminated with a 652-nm laser light and a fluence of 10 J/cm 2 , 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 2 1 ⁄2 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 photother-apy 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. References 1 Schouwink H, Rutgers ET, Van Der Sijp J, et al. Intraoper-ative photodynamic therapy after pleuropneumonectomy in patients with malignant pleural mesothelioma: dose finding and toxicity results. margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: results in 183 patients. Patterns of failure after trimodality therapy for malignant pleural mesothelioma. A phase II trial of surgical resection and adjuvant high-dose hemitho-racic radiation for malignant pleural mesothelioma. We 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 pneumonec-tomy combined with chemotherapy and radiotherapy and some aspects of the use of photodynamic therapy (PDT) after resec-tion. In this study, the perioperative mortality is only 3.8% and the median survival is 19 months. Although the survival was not calculated …