Why are some patients diagnosed with malignant pleural mesothelioma candidates for surgery and some are not? Why do some have their pleura removed and some have their lung and their diaphragm removed? Do some surgeons prefer one surgery over the other?
There are no easy, quick answers in the options of treatment for malignant pleural mesothelioma. Being a rare disease, the studies regarding treatment are limited. Over the past decade there has been some controversy among experts regarding what procedure for what stage of disease, or if surgery should be an option.
Surgical options for patients with malignant pleural mesothelioma are dependent on the stage of disease that patient is in, the cell type, their performance status, and the results of the pre-screening tests done. Most patients diagnosed with malignant pleural mesothelioma are not candidates for surgery. The reasons that they are not candidates are varied: stage of disease and cell type, are all factors that have been identified and refined in the last few years.
When surgery is an option the choices are usually an extended pleurectomy or an extra-pleural pneumonectomy. Both of these options should be performed at specialized mesothelioma centers, with a dedicated team of mesothelioma experts, after careful consideration and tests. It is the mesothelioma expert surgeon, with experience and judgement who leads the team, who ultimately decides which option is offered to the patient.
A pleurectomy is by definition a removal of part of the pleura – the lining outside of the lung. The extended pleurectomy/ decortication the lung is left in place, all gross tumor is removed.
An extra–pleural pneumonectomy one of the lungs is removed along with the part of the diaphragm, the pleura, and sometimes the pericardium, the lining around the heart.
Within the mesothelioma community there is some discussion regarding what the best procedure is that produces the best outcomes.
According to the latest guidelines recently published by the American Society of Clinical Oncology in February 2018 in selected patients with early-stage disease, it is strongly recommended that a maximum surgical resection be performed. “Surgery is performed as part of the treatment plan, not as the sole treatment. The goal of any surgery on patients with mesothelioma is maximum removal of all tumor visible to the naked eye.”
The guidelines further explain that when offering surgery that a pleurectomy should be offered first and an extra pleural pneumonectomy should be offered to only highly selected patients in a mesothelioma center of excellence. The patients with the best outcomes for extra-pleural pneumonectomy have been found to be patients that have early stage disease, localized disease, good functional status, and epithelial cell type.
This is a complicated issue. Some experts believe that only pleurectomy should be performed and rarely extra pleural pneumonectomy. The reason for this is that statistically EPP’s have a higher complication rate and the overall survival is not long enough to justify this extensive procedure.
There are no randomized trials that compare EPP versus pleurectomy. In retrospective studies pleurectomy decortication has been found to have less mortality, less morbidity and a comparable overall survival. Over the past few years results have improved for the surgical procedures, due to more precise staging, anesthesia, improvements in surgical techniques and reconstruction, post-op management, and criteria in patient selection.
The choice to go to a mesothelioma center can potentially open up options for patients diagnosed with malignant pleural mesothelioma. If surgery is an option it is done after careful thought, and planning about your individual tumor. There is no one size fits all. What is an option for one might be off the table for the next patient
Some centers and doctors are more aggressive than others. Every patient and their disease is different, the decision to operate is made with the patient, who is fully informed of the risks and benefits.
Whatever surgery is recommended the patient needs to have confidence, communication and trust in their surgeon, and specialized mesothelioma team, while undergoing treatment for malignant pleural mesothelioma.
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