The best mesothelioma surgery is the one the patient can tolerate with the fewest serious side effects. That’s according to a new study from MD Anderson researchers.
Their goal was to help settle the ongoing debate over which type of pleural mesothelioma surgery is most effective.
Both EPP and P/D surgery are major operations. But one causes much more serious side effects than the other. So how do doctors and patients decide on the best mesothelioma surgery for their case?
The new research suggests there may not be a definitive answer.
Debate Over the Best Mesothelioma Surgery
Pleural mesothelioma is an asbestos-linked cancer of the membrane around the lungs. During EPP (extrapleural pneumonectomy) surgery, doctors remove this membrane, any other evidence of cancer, and the closest lung.
Some of the top mesothelioma doctors in the world believe that EPP is the best mesothelioma surgery because it removes more of the cancer. But it is a risky operation with a high rate of complications and even death.
In some ways, P/D surgery (pleurectomy with decortication) is similar to EPP. Surgeons remove as much diseased tissue as they can see. They scrape any evidence of cancer away from the surface of the lungs. But they do not remove either of the lungs. Many surgeons now think P/D is the best mesothelioma surgery because it is easier on the patient.
No Clear Answer
Studies comparing the two surgeries have produced mixed results. Centers that do more EPP surgeries are likely to have better results with this operation. The same is true with centers that do more P/D. The MD Anderson team tried to make all things equal for a fair determination of the best mesothelioma surgery.
They started with a list of 282 pleural mesothelioma patients. These patients had operations at MD Anderson between 2000 and 2019. One hundred and eighty-seven of these patients underwent EPP. The remaining 95 had P/D.
“Even with propensity score matching, perioperative mortality was significantly higher for EPP than for P/D,” says lead author Nicolas Zhou.
But those deaths do not tell the whole story of which is the best mesothelioma surgery. Several factors played a role in how long patients survived after either operation.
People with the most complete removal of their tumors, those with the epithelioid subtype, those who had radiation afterward, and those who had their operations more recently all did better – regardless of which operation they had.
“In a multimodality treatment setting, P/D and EPP had comparable long-term oncological outcomes,” writes Dr. Zhou.
The study does not recommend one surgery over the other. Instead, Dr. Zhou and his colleagues say the best mesothelioma surgery is the one that is best suited for the patient’s subtype, treatment plan, and overall health.
“The goal of surgical cytoreduction should be macroscopic complete resection achieved by the safest operation a patient can tolerate,” they write.
Zhou, N, et al, “Extrapleural Pneumonectomy versus Pleurectomy/Decortication for Malignant Pleural Mesothelioma”, May 7, 2021, Annals of Thoracic Surgery, Online ahead of print, https://www.annalsthoracicsurgery.org/article/S0003-4975(21)00846-8/pdf