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Study Finds Higher Risk with Mesothelioma EPP Surgery

Yet another team of researchers is weighing in on the ongoing debate over the different kinds of surgery for malignant pleural mesothelioma and the news is not good for patients considering the most invasive approach.

The newest study involved thoracic surgeons from Stanford University and UCLA, Cardiothoracic surgeons from the University of Chicago and the University of Washington, and Biostatisticians from Duke University. Together, the researchers analyzed the outcomes of 225 mesothelioma patients from the Society of Thoracic Surgeons-General Thoracic Database who underwent either pleurectomy/decortication (P/D) or the more radical extrapleural pneumonectomy (EPP).

Pneumonectomy literally means removal of the lung. As the most invasive pleural mesothelioma surgical approach, EPP involves removing the entire pleural lining where mesothelioma starts, as well as the lung closest to the tumor, all or part of the diaphragm, and other at-risk tissues. The operation carries a high risk of complications and even death, but some studies have suggested that it may give pleural mesothelioma patients their best hope of survival.

The more conservative surgery called P/D involves removing the pleural lining that encases the lungs and scraping any cancerous lesions off of the surface of the lungs. It may also involve removing portions of the diaphragm and the pericardium which surrounds the heart and is also at risk for mesothelioma metastasis.

In the new study, 130 patients had the P/D procedure while 95 underwent EPP. These included surgeries done in 3 centers that did higher volumes of P/D cases and 2 centers that specialized in EPP. The researchers reported that mesothelioma patients in both groups were similar, except that the EPP patients tended to be younger and were more likely to have had some chemotherapy before surgery.

Summarizing their findings for the Journal of Thoracic and Cardiovascular Surgery, lead author Bryan Burt, MD, writes, “Major morbidity was greater after extrapleural pneumonectomy, including acute respiratory distress syndrome (8.4% vs 0.8%; P = .005), reintubation (14.7% vs 2.3%; P = .001), unexpected reoperation (9.5% vs 1.5%; P = .01), and sepsis (4.2% vs 0%; P = .03), as was mortality (10.5% vs 3.1%; P = .03).”

Based on these findings, the team concluded that EPP was “an independent predictor of major morbidity or mortality” in people with mesothelioma. They did concede, however, that the effects of higher volumes of surgery on a cancer center’s success with each type of mesothelioma surgery deserved further study.

The type of mesothelioma surgery to have is one of the most important decisions a patient can make and is based on a variety of factors involving both the patient and the surgeon. Although P/D carries a lower risk of major complications, EPP has consistently been shown to provide a survival benefit in younger mesothelioma patients and those in better overall health.The medical community remains divided on the risks and benefits of these two surgical approaches.


Burt, BM et al, “Malignant pleural mesothelioma and the Soceity of Thoracic Surgeons Database: An analysis of surgical morbidity and mortality”, March 14, 2014, Journal of Thoracic and Cardiovascular Surgery, Epub ahead of print,

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