mesothelioma treatment

The 4th International Symposium on Lung Sparing Therapies for Malignant Pleural Mesothelioma showed the spotlight on lung-sparing surgical techniques, lung-sparing adjuvant therapies, supportive therapies and potential future adjuvant therapies on June 7th, 2014.

EPP and P/D Surgeries

As a brief review, surgery for mesothelioma in the chest (pleural) cavity uses one of two general approaches: Extrapleural pneumonectomy and pleurectomy/decortication (P/D) surgery. Extrapleural pneumonectomy removes the parts of the organs touching the chest wall near or infiltrated by the mesothelioma. The removed parts include the part of the lung, diaphragm (muscle which helps you breathe), lining of the chest cavity (pleura), and the pericardium (lining around the cavity containing the heart). They are usually removed as a block of tissue (en-bloc).

In contrast, a pleurectomy/decortication (P/D) surgery removes the lining of the chest cavity (pleura) that harbors the mesothelioma and does not remove any lung tissue. The surgical strategy called “extended pleurectomy/ decortication” also removes any diaphragm and pericardium that has tumor growing on it. Many surgeons use pleurectomy/decortication for early stage patients because the tumor has not yet infiltrated into the other organs yet. Surgeons often use extrapleural pneumonectomy (EPP) in later stage patients because their tumor has infiltrated the other structures.1

Complications caused by air leaks can reduce Quality of Life and may occur after either procedure.

At the last International Mesothelioma Interest Group meeting in Boston in 2012, experts agreed that the surgical team, with their expertise and judgment, use various clinical factors such as extent of disease to choose between extrapleural pneumonectomy (EPP) and pleurectomy/decortication for the best option for each individual patient.1

What Are The Different Outcomes of EPP and P/D Surgeries?

Several groups have previously compared the two techniques and found no significant differences in outcomes. Dr. Robert Cameron, a course organizer and course contributor to the symposium and a strong supporter of lung-sparing mesothelioma treatments, discussed their recent comparative study on 225 mesothelioma patients at 48 medical centers.2, 3 Mesothelioma patients who received extrapleural pneumonectomy (EPP) surgical treatment had significantly greater incidence of severe disease symptoms (morbidity). Patients treated with EPP (n=95) had a significantly higher rate of the following complications than those treated with pleurectomy/decortication (P/D) (n=130):2

  1. acute respiratory distress syndrome (EPP 30.1% vs P/D 17.8%),
  2. requirement for reintubation (EPP 14.7% vs P/D 2.3%),
  3. severe infection or sepsis (EPP 4.2% vs P/D 0%); and
  4. unexpected reoperation (EPP 9.5% vs P/D 1.5%).

Patients treated with EPP also experienced a significantly higher rate of death (10.5%) than those treated with P/D (3.1%, P=0.001).

Each patient’s surgical team considers the characteristics of each patient’s mesothelioma and Quality of Life issues and concerns during the process of recommending treatment options.

Other Treatment Considerations

The meeting also discussed the timing of chemotherapy. Several groups are indicating that chemotherapy before surgery (called induction therapy) helps reduce tumor significantly in 30-40% of mesothelioma patients.1 It may reduce complications after EPP surgery, at least at some medical centers. The overall survival of mesothelioma patients that received chemotherapy before surgery (induction therapy) were similar to those who received chemotherapy after surgery (adjuvant chemotherapy).1

We discuss these different treatment options to help patients and family members understand the different procedures being considered by each surgical team for each individual patient.