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Posted on Tuesday, Jan 27, 2009

Pleural Mesothelioma and Surgery

Article: Surgery for Malignant Pleural Mesothelioma

Malignant mesothelioma is one of the most difficult diseases in all of medicine to manage effectively. Median survival time typically averages only 12-14 months. For patients lucky enough to receive a diagnosis in the disease’s earliest stages, median survival can sometimes be extended two or three years, but a complete cure remains impossible and the vast majority of people who are diagnosed with pleural mesothelioma or peritoneal mesothelioma will eventually die from the disease. Because of this disappointing situation, physicians and scientists all over the world are searching for more effective treatments. In some cases, this research may focus on the investigation of a novel therapeutic strategy; in other cases, it may focus on improving a current treatment modality or on comparing the effectiveness of competing modalities when a standard-of-care has not yet been established.

One of the most controversial questions in contemporary mesothelioma treatment research concerns the choice of pleurectomy/decortication (P/D) vs. extrapleural pneumonectomy (EPP) for the surgical management of pleural mesothelioma. Both of these treatments are highly invasive procedures and both are properly considered radical surgery, but there is not yet clear guidance on which surgery should be performed for what patient. EPP is considered the more invasive of the two procedures, so some physicians will perform P/D on early-stage patients and EPP on late-stage patients, but a standard does not exist which actually specifies this. In many cases, the question of procedure will be based on a physician’s personal history in treating the disease. A number of retrospective studies have been performed, but direct comparison of their results is impossible due to differences in study design, staging guidelines, reporting and a host of other factors. However, these studies are still helpful for the working physician and many doctors will look at these studies in an attempt to draw some conclusions from their findings.

In an article recently published in the Annals of Diagnostic Pathology, David Rice, MB, BCh, FRCSI, of the MD Anderson Cancer Center, summarized much of the available literature on the treatment of pleural mesothelioma and addressed the controversy of P/D vs. EPP as well. He stated that the goal of any curative surgery should be the removal of all macroscopic evidence of disease, but that the available evidence does not indicate which procedure should be the one deployed for this purpose, because neither shows any greater long-term survival when compared to the other. EPP has demonstrated better rates of local disease control than P/D has and it more readily allows the use of radiation than does pleurectomy/decortication, which are important factors in its favor. However, EPP is also associated with a greater risk of serious side effects and of treatment-related death than is pleurectomy/decortication. It is also associated with a greater likelihood of metastatic spread of the disease. Because of this situation, the choice regarding which procedure is more effective is still an open question. Dr. Rice does say, however, that should physicians be able to stop the metastasic spread of the disease, then EPP would likely lead to longer survival in patients who are able to tolerate it.