Open lung-sparing surgery for malignant pleural mesothelioma: the benefits of a radical approach within multimodality therapy

Department of Thoracic Surgery, Glenfield Hospital, Groby Road, Leicester LE3 9QA, United Kingdom.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery (Impact Factor: 3.3). 10/2008; 34(4):886-91. DOI: 10.1016/j.ejcts.2008.06.010
Source: PubMed


To identify the optimal debulking procedure in patients with malignant pleural mesothelioma who are not suitable for extrapleural pneumonectomy (EPP).
We reviewed 102 consecutive patients (93 male; 9 female, mean age 63 years) who were not suitable for EPP because of either advanced tumour stage or suboptimal fitness. Patients underwent either a non-radical tumour decortication to obtain lung expansion (group NR) or latterly a radical pleurectomy/decortication to obtain macroscopic tumour clearance (group R). We analysed the comparative perioperative courses and long-term survival.
The two groups were similar for age and gender distribution but epithelioid type was more predominant in group R: 78% compared to 55% epithelioid in group NR. Thirty-day mortality was similar (5.9% in group R and 9.8% in the group NR, p=0.36) but 90-day mortality was significantly higher in the group NR (29.4% vs 9.8% in group R, p=0.012). More patients in group R received adjuvant chemotherapy (65% vs 28%, p=0.000) and radiotherapy (65% vs 26%, p=0.000). Median survival for all cell types was significantly higher in group R (15.3 months vs 7.1 months, p<0.000). Group R survival rates at 1, 2, 3 and 4 years were 53, 41, 25 and 13%, respectively while for group NR they were 32, 9.6, 2 and 0%, respectively. For epithelioid cell type there was still a significant median survival advantage in group R (25.4 months vs 10.2 months, p<0.000), but there was no difference for sarcomatoid (9.3 months vs 3.2 months, p=0.16) or biphasic cell types (9.4 months vs 7 months, p=0.38).
If a patient with epithelioid MPM is fit enough to tolerate a thoracotomy then macroscopic clearance of the tumour is the preferred option as part of a multimodality regime including chemotherapy.

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Available from: Apostolos Nakas,
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    • "Therefore, discrepancies concerning performance practices and recommendations for P/D and EPP clearly exist. Furthermore, many MPM centers in Europe and some in North America and Japan are currently performing P/D with curative intent [20, 21, 28, 29, 33–37]. "
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    ABSTRACT: Malignant pleural mesothelioma (MPM) is associated with a very poor prognosis. Unlike other solid tumors, any type of planned surgery for MPM would be cytoreductive rather than radical. There are two types of surgery for MPM. Extrapleural pneumonectomy (EPP) involves en bloc resection of the lung, pleura, pericardium, and diaphragm. Pleurectomy/decortication (P/D) is a lung-sparing surgery that removes only parietal/visceral pleura. In comparison with EPP, P/D is theoretically less radical but is associated with less perioperative mortality/morbidity and less postoperative deterioration of cardiopulmonary function. It still remains unclear which surgical technique is superior in terms of the risk/benefit ratio. In this context, selection between EPP and P/D has been a matter to debate.
    General Thoracic and Cardiovascular Surgery 03/2014; 62(9). DOI:10.1007/s11748-014-0389-7
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    • "Nakas et al. [26] maintained a prospectively updated database which they used to analyse patients that underwent P/D only. These were patients unfit for EPP. "
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    ABSTRACT: Introduction. Malignant pleural mesothelioma (MPM) is an aggressive cancer arising from pleural mesothelium. Surgery aims to either cure the disease or control the symptoms. Two surgical procedures exist: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). In this systematic review we assess current evidence on safety and efficacy of surgery. Methods. Five electronic databases were reviewed from January 1990 to January 2013. Studies were selected according to a predefined protocol. Primary endpoint was overall survival. Secondary endpoints included quality of life, disease-free survival, disease recurrence, morbidity, and length of hospital stay. Results. Sixteen studies were included. Median survival ranged from 8.1 to 32 months for P/D and from 6.9 to 46.9 months for EPP. Perioperative mortality was 0%-9.8% and 3.2%-12.5%, respectively. Perioperative morbidity was 5.9%-55% for P/D and 10%-82.6% for EPP. Average length of stay was 7 days for P/D and 9 days for EPP. Conclusion. Current evidence cannot definitively answer which procedure (EPP or P/D) is more beneficial in terms of survival and operative risks. This systematic review suggests that surgery in the context of trimodality therapy offers acceptable perioperative outcomes and long-term survival. Centres specialising in MPM management have better results.
    02/2014; 2014:817203. DOI:10.1155/2014/817203
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    • "The surgical role in the management of malignant pleural mesothelioma remains a matter of debate. The outcome of extrapleural pnemonectomy in the context of trimodality therapy was good in some centres [4]. However, EPP surgery is associated with a high mortality and morbidity rate (3.4— 5%) and (22—50%), respectively, even in the fittest of patients [3,7—9]. "
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    ABSTRACT: To determine whether there is a survival benefit from open-lung-preserving surgery (radical decortication) for malignant mesothelioma, when compared with the non-radical approach in the mesothelioma and radical surgery (MARS)-trial era. We compared outcomes between 13 patients with malignant mesothelioma, who underwent radical decortication (group RD, n = 13) with 13 case-matched patients, who had palliative surgery (group non-radical decortication (NRD), n = 13) over a period of 2 years from June 2006 onwards. Patients were matched for age, sex, histology, computed tomography (CT) stage, haematological indices, body mass index (BMI) and adjuvant chemotherapy. We compared perioperative and postoperative courses and long-term survival. Histology was 25% biphasic and 75% epithelioid in both the groups. There was no significant difference in the proportions receiving adjuvant chemotherapy (54%, p = 1.00), but more patients in the RD group received adjuvant radiotherapy (46% vs 15%, p = 0.20). Median survival was higher for all cell types in the RD group (16.9 months vs 6.8 months, p = 0.001). Radical open-lung-sparing surgery may confer a survival advantage to patients with malignant mesothelioma, who are fit to undergo radical decortication followed by chemotherapy and radiotherapy. Trials of radical surgery versus no surgery should include lung-sparing operations.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 03/2011; 39(3):360-3. DOI:10.1016/j.ejcts.2010.06.006 · 3.30 Impact Factor
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