The heads of a European working group charged with advising cardio-thoracic surgeons on the best ways to treat malignant pleural mesothelioma say the most radical and risky type of surgery is not clinically effective.
Dr. Giuseppe Cardillo of Carlo Forlanini Hospital in Rome and Dr. Tom Treasure with University College London (author of the MARS mesothelioma surgery study) detail their conclusion in a Letter to the Editor in the Annals of Surgery.
While the two acknowledge that some studies appear to support the use of extrapleural pneumonectomy (EPP) as a mesothelioma treatment, they say these studies are flawed and do not paint a true picture of the grim post-surgical outlook for most mesothelioma patients.
Lung-Removal versus Lung-Sparing Surgery
EPP is the most extensive type of surgery for pleural mesothelioma. This major operation involves the removal of one lung as well as the diseased pleural membrane, all or part of the diaphragm, the pericardial membrane around the heart, and other at-risk tissues. It carries a high risk for complications.
Pleurectomy with decortication (PD) is an alternate mesothelioma surgery that involves removal of many of the same tissues but leaves both lungs intact.
Although some studies suggest that carefully selected mesothelioma patients live longer after EPP, Cardillo and Treasure point out that, because only the healthiest patients are candidates for this approach, the results are skewed in favor of longer survival.
What Do the Studies Say?
A 2014 study published in the Annals of Surgery by Dr. David Sugarbaker, a top practitioner and advocate of EPP, suggests that mesothelioma survival after surgery hinges on the level of lymph node involvement. It also notes that the surgery has been refined and improved with experience, resulting in better survival odds.
But Cardillo and Treasure point, instead, to a larger 2010 study that reached a different conclusion.
“On the contrary, among patients in a large published data set of 945 patients under consideration for possible surgery, there was no survival difference between those not operated on and those who had an exploratory thoracotomy without resection,” the pair write.
In this study, published by Dr. Treasure and two University College London colleagues, patients survived mesothelioma for an average of 17 to 18 months regardless of what kind of treatment they ultimately underwent.
A 2008 study conducted by nationally-known mesothelioma researchers Dr. Raja Flores and Dr. Harvey Pass found poorer survival after EPP even though the PD surgery was reserved for the sicker patients.
A Way Forward for Mesothelioma Doctors
The debate over the most effective surgical approach to pleural mesothelioma has been going on for years, with some of the top names in the field coming down on either side of the issue.
But Cardillo and Treasure, whose working group was commissioned by the European Association for Cardio-Thoracic Surgery, say there is now enough evidence to guide mesothelioma doctors as they advise their patients.
“The accumulated evidence points away from EPP as clinically effective and, if taken in its totality, the published evidence now allows those advising patients to give informed counsel,” concludes the letter.
Cardillo, G and Treasure, T, “Extrapleural Pneumonectomy is Not Shown to be Clinically Effective in the Treatment of Malignant Pleural Mesothelioma”, March 7, 2017, Annals of Surgery