Few medical treatments make as much intuitive sense as surgery. When something inside is broken or diseased or useless, the right surgery can often repair it or remove it. Cancers can be especially susceptible to surgical cures, particularly when combined with chemotherapy and radiation.
Malignant pleural mesothelioma, however, defies any such quick fix. Unlike solid tumors, most cases of mesothelioma grow as a sheet or layer, so they are rarely confined along easily reached contours. This makes the surgeon’s job much tougher than simply going in and cutting out a cancerous lump.
Mesothelioma tumors, since they grow as diffuse sheets of cancer, can be enormous. Seven to ten-pound tumors are common, and they can be so thick, widespread, and hardened into an impenetrable rind that they are virtually inoperable. Mesothelioma tumors can penetrate the chest wall and spread so that no degree of surgical skill can cut them out, or they can attach to sensitive organs like the aorta, making removal impossible.
The meaning of success
Despite these barriers, skilled surgeons who specialize in the treatment of mesothelioma can often perform successful surgery. Yet the success of such surgery is very different from a successful operation to repair a broken bone or replace a heart valve.
Note to Meso Patients
Physician with Meso Urges you to Read Dr. Cameron’s article before consenting to any treatment.
A pleurectomy/decortication (P/D) is an operation for mesothelioma that removes the involved pleura and frees the underlying lung so that it can expand and fill the pleural cavity.
The pleural space is a potential cavity between the lung and the chest wall-more specifically, between the visceral pleura and the parietal pleura. In the average healthy patient, this space is less than 1 mm thick. There are a number of pathologic processes that can alter the transport of cells and fluid within this space and thus give rise to clinically significant sequelae.
One such process is fibrothorax, which is defined as the presence of abnormal fibrous tissue within the pleural space, resulting in entrapment of the underlying pulmonary parenchyma (a state variously referred to as trapped lung, restrictive pleurisy, or encased lung).
Decortication is the surgical procedure by which this restrictive fibrous layer is peeled away from the lung; the literal meaning of the term is the stripping away of a rind. The technical goals of the operation are to re-expand the lung and resolve the pathologic process affecting the pleural space so that pulmonary function and chest wall mechanics will improve and the patient’s symptoms will be relieved.
Steps in P/D Operative Technique for Malignant Pleural Mesothelioma:
- Incision and exposure of parietal pleura
- Dissection of parietal pleura from endothoracic fascia, diaphragm, and mediastinum
- Incision of the parietal pleura and exposure of the visceral pleura
- Decortication of the visceral pleura
Extra-pleural pneumonectomy (EPP) is a surgical procedure that involves the removal of the lung along with its coverings and the associated coverings of the heart, diaphragm and pericardium.
Steps in EPP Operative Technique for Malignant Pleural Mesothelioma:
- Incision and exposure of parietal pleura
- Dissection of parietal pleura from endothoracic fascia, diaphragm, and mediastinum*
- Control and division of pulmonary vessels, subcarinal node dissection, staple main stem bronchus
- En bloc resection of lung, pleura, pericardium and diaphragm
- Reconstruction of diaphragm, pericardium
P/D versus the EPP
From a 2006 article in the Annals of Surgical Oncology:
- There is no evidence that the radical EPP is superior to lung-sparing P/D
- Both surgeries carry potentially serious risks
- Only experienced surgeons should attempt either surgery
- “The EPP should not become the Sir Edmund Hillary operation of Thoracic Surgery: being done simply because it is there and because it can be done.
For further discussion of this topic, please see: Dr. Robert Cameron on Treating Mesothelioma: “Lung-Saving P/D vs. Radical EPP”
For videos of Dr. Cameron where he discussed mesothelioma, how it is caused, how it is diagnosed and how it is treated, click here.
UK MARS Trial Debunks the Radical EPP
LOS ANGELES. This well-designed seminal study from Tom Treasure and his colleagues in England, while small, provides compelling and incontrovertible evidence that supports our long-held position at The Pacific Meso Center that the use of radical lung-removing surgery, ie., EPP, is completely unsupported by medical data.
Click Here to see published medical articles comparing pleurectomy/decortication to extra pleural pnemonectomy.