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Meta-Analysis Finds Lung-Sparing Surgery the Best Option for Most Mesothelioma Patients

There is now more evidence to support the growing number of experts who favor lung-sparing P/D surgery over radical extrapleural pneumonectomy (EPP) for the treatment of malignant pleural mesothelioma.

There has been an ongoing debate within the surgical community over which procedure carries the most benefit with the least risk.

The late David Sugarbaker, MD, of Baylor St. Luke’s Medical Center in Houston was a pioneer of the EPP procedure, which involves removing not only the diseased pleural lining where mesothelioma tumors grow, but also the nearest lung, most of the diaphragm, the pericardium, and other at-risk tissues.

But it turns out that, although Sugarbaker and his team were able to show a mesothelioma survival benefit with EPP, their results, based on years of experience, were not typical.

P/D Versus EPP for Mesothelioma Treatment

According to the authors of an updated meta-analysis of survival after EPP versus P/D, which stretches back to 1990, the median overall survival was “significantly increased” in the P/D group.

At the same time, the risk of death within 30 days of mesothelioma surgery was significantly higher among the patients who had EPP, as was the incidence of serious — and even life-threatening — side effects.

“The incidence of postoperative atrial fibrillation, hemorrhage, empyema, bronchopleural fistula and air leak was significantly increased in the EPP group,” writes lead author Dimitrios Magouliotis, a surgeon with Greece’s University Hospital of Larissa.

Meta-Analysis Includes Past Mesothelioma Studies

A meta-analysis is essentially a study of studies.

The meta-analysis conducted by Dr. Magouliotis and his colleagues and published in General Thoracic and Cardiovascular Surgery, took data from 15 previous studies between 1990 and 2018 and included a total of 1,672 patients with pleural mesothelioma.

Despite the higher incidence of side effects among the EPP patients, the risk of death within 90 days, and 1-, 2-, or 3- years did not differ significantly between those who had the more extensive surgery and those whose lungs were left in place.

Researchers say, given all the evidence from multiple different centers, P/D is the clear winner between the two types of mesothelioma surgery.

“The present meta-analysis indicates that P/D is associated with enhanced outcomes regarding 30-day mortality, median overall survival, and complications,” concludes Dr. Magouliotis. “The P/D approach should, therefore, be preferred when technically feasible.”

Even so, the team acknowledges that surgery choice is a highly individualized decision that must take into account the patient’s disease status, as well as the experience of the surgeon.

Multiple studies have found that mesothelioma patients who receive care in larger, more experienced cancer centers have better outcomes. Mesothelioma, or asbestos cancer, is an extremely rare malignancy accounting for just 2,500 deaths in the US each year. As a result, smaller hospitals and doctors in smaller communities may rarely, if ever, see a case.


Magouliotis, DE, et al, “Updated meta-analysis of survival after extrapleural pneumonectomy versus pleurectomy/decortication in mesothelioma”, October 26, 2018, General Thoracic and Cardiovascular Surgery, https://link.springer.com/article/10.1007/s11748-018-1027-6

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