Surgical Choices For Mesothelioma
The most common forms of mesothelioma treatment include a combination of surgery, radiation, and chemotherapy.
Surgical resection of mesothelioma can be accomplished through an extrapleural pneumonectomy (which removes the entire affected lung and sacs) or through a less radical pleurectomy with decortication (which removes only the affected lining of the lungs but leaves the lung in place). Much debate and research exists regarding these two methods of surgical resection.
Other forms of surgical treatment offer palliative effects including a talc pleurodesis, a procedure to inject a sclerosing agent such as talcom powder into the chest to prevent further fluid accumulation. This procedure is not intended to be curative, but rather eliminates the symptoms of mesothelioma.
Patients who undergo surgery as a first line treatment may also be candidates for future aggressive treatment, as well. Call our office (310) 478-4678 to learn about surgeons who specialize in these procedures. Get all the information to decide what treatment is best for you.
Pleurectomy/Decortication vs Extra-Pleural Pneumonectomy
Talc Pleurodesis or Thoracoscopic Talc Poudrage (TTP) Pleurodesis
Mesothelioma patients usually experience discomfort in the chest and shortness of breath caused by accumulation of fluid around the lung, known as pleural effusions. Talc pleurodesis is a palliative surgical procedure designed to alleviate these symptoms. It is lower cost than radical surgery and is associated with a shorter hospital stay. In this procedure, the space between the layer of tissue surrounding the lungs and lining the chest wall (called the pleura) is eliminated by using an irritant such as talc powder to create inflammation. This joins the tissues together, thus not allowing space for fluid build-up.
TP Articles: To read the literature providing support for the use of TTP as a primary palliative treatment option, please visit Important Articles. These studies assert that TTP is safe, has low-morbidity, and is less expensive than other treatments, and that it has a high success rate for relieving symptomatic pleural effusions.
Pleurectomy/Decortication
Pleurectomy with decortication (P/D) is a lung-sparing surgery which involves the removal of the parietal pleura (the membrane lining the thoracic wall) and decortication of the visceral pleura (the membrane lining of the lung). Part of the diaphragm and/or the pericardium (the membrane lining the heart) may also be removed, depending on the extent of the tumor. There is a risk of local recurrence of disease, however this procedure is comparable in survival rates to the more radical extrapleural pneumonectomy, and is associated with higher post-operative quality of life.
Dr. Robert Cameron, Director of the Mesothelioma Program at UCLA, has performed this surgery for qualifying patients for over a decade. His approach of "less is more" guides his work in removing all visible tumor while keeping the healthy, often uninvolved lung intact. His philosophy also translates into his multimodal approach including radiation and maintenance therapy.
Dr. Cameron gave the below presentation to the Society of Thoracic Surgeons in 2006 to demonstrate that "maintenance therapy" such as interferon alpha may have a role in treating mesothelioma patients. The median survival of patients who underwent his pleurectomy with decortication, followed by radiation and maintenance therapy of interferon alpha was 37 months. We recommend you view the presentation and abstract below.
1-30-2006: "Improved Survival with Interferon Alpha Maintenance Therapy Following Pleurectomy/Decortication and Radiation for Malignant Pleural Mesothelioma," as presented by Dr. Robert Cameron to the Society of Thoracic Surgeons, January 30, 2006.
9-14-05: Anatomy of a Pleurectomy with Decortication (photos). Dr. Robert Cameron, September 13, 2005
In one retrospective study, Drs. Terry T. Lee et al assert that the multi-modal approach of performing a pleurectomy/decortication followed by radiotherapy and, in some cases, chemotherapy appears to be a comparably successful alternative to extrapleural pneumonectomy. In the study, 32 patients with malignant pleural mesothelioma were evaluated between 1995 and 2000. The median overall survival was reported to be 18.1 months. The median interval between operation and the progression of the tumor was 12.2 months. Surgery does not completely eradicate all tumor, and local control was the main problem encountered. For this reason, adjuvant therapies such as post-surgery radiation and/or chemotherapy or intra-operative hyperthermic chemo perfusion are needed.
In another study, Dr. Valerie Rusch et al investigated the effectiveness of a combined modality treatment consisting of surgical resection followed by intrapleural chemotherapy and then systemic chemotherapy. A median survival of 17 months was observed for the 27 patients who underwent pleurectomy/decortication and subsequent chemotherapy treatment. The survival rate at one year was 68% and 40% at two years. As was also stated in this study, local control was the most prominent difficulty in preventing relapse. The researchers found this treatment technique to be comparable to and in some cases better than other multimodality approaches, also concluding that improvement in local control is needed.
P/D Articles: To read the literature providing support for the use of P/D as a primary treatment option for mesothelioma, please visit Important Articles. These studies assert that P/D is safe, has low-morbidity, and has comparable results to the EPP.
Extra-Pleural Pneumonectomy
An extrapleural pneumonectomy (EPP) is a surgery which removes one lung and part of the parietal pleura. It also removes the diaphragm and the pericardium.
A report by Treasure et al, calls attention to the growing need for mesothelioma research and subsequent improvements in treatment. It can take twenty to forty years for mesothelioma symptoms to develop, putting patients at a disadvantage for catching the disease in its earliest stages. Surgery and adjuvant therapies are currently the most successful options for mesothelioma treatment, with reports in the UK of five-year survival rates as high as 48% in selected subsets of patients with favorable histology and no nodal metastases.
In a study in Japan, Okada et al carried out a retrospective review of 34 patients who underwent P/D surgery and 31 patients who underwent EPP. They found the median survival after P/D to be 17 months, and 13 months after EPP. The survival rate at three years was 24% and 33%, respectively. An analysis of the data revealed that older age, non-epithelial histology, and stage III-IV disease are negatively contributing factors. The surgical procedure performed was not shown to impact the outcome.
EPP, as with most radical surgeries, is associated with perioperative morbidity and mortality. A study conducted by Sugarbaker et al, sought to identify ways to reduce such complications. Between 1980 and 2000, 328 patients were examined for morbidity data and mortality rates. The researchers concluded that mortality can be minimized by early detection and aggressive treatment, and that morbidity complications require unique, individualistic approaches to appropriate treatment.
In general, surgery cannot remove all microscopic traces of disease. A common difficulty with surgery is the rate of local recurrence. For this reason, radiation therapy is often administered after surgery. Rusch et al conducted a study of 57 patients who underwent surgery and adjuvant radiation. At a dose of 54Gy, it was well-tolerated for most patients. For stage I and II tumors, the median survival was 33.8 months. Locoregional and/or distance recurrence occurred in 37 patients. While the use of radiation appears to greatly reduce local recurrence, later-stage tumors had a higher risk of early distant relapse.
Multi-modality treatments may provide relief from the morbidity and mortality associated with EPP. Grondin and Sugarbaker conducted a study of 183 patients who underwent multi-modality treatment, including EPP with radiotherapy and chemotherapy. EPP alone is associated with long-term disease-free survival, but also has had higher rates of mortality than P/D and reduced quality of life due to resulting morbidity. Recent improvements in operative technique and stricter patient selection have reduced the mortality rate resulting from EPP. The use of adjuvant therapies may contribute to better survival in certain patients.
EPP articles: To read the literature providing support for the use of EPP as a primary treatment option for mesothelioma, please visit Important Articles. These studies review EPP in treating mesothelioma and include a video of the EPP surgery performed by Dr. David Sugarbaker.
Pleurectomy/Decortication vs Extra-Pleural Pneumonectomy
Much debate and research exists regarding these two methods of surgical resection in treating mesothelioma. Because no randomized clinical studies have been conducted to compare P/D to EPP, much of the survival data, quality of life issues, as well as the techniques behind the surgeries remain unproven.
Dr. Robert Cameron favors sparing the lung through the pleurectomy with decortication surgery. His rationale is:
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There is no evidence the EPP is superior to the lung-sparing P/D
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Both surgeries carry potentially serious risks
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Only experienced surgeons should attempt either surgery
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"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."
1-31-07: Extrapleural Pneumonectomy Is the Preferred Surgical Management in the Multimodality Therapy of Pleural Mesothelioma: Con Argument. Robert B. Cameron, MD. David Geffen School of Medicine at UCLA.
Dr. Cameron's argument against the EPP fleshes out many of the most significant pros and cons behind each surgery. This is a must read for patients decided between surgeries.
1-16-06: Consensus Report: Pretreatment Minimal Staging and Treatment of Potentially Resectable Malignant Pleural Mesothelioma. J. Meerbeeck, M. Boyer.
This report shows
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There is no evidence the EPP is superior to the lung-sparing P/D.
- There is no evidence that multi-modal therapy is superior since clincial trials are not appropriately designed and risk selective patient recruitment.
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A new, uniform clinical staging system is needed, along with a large clinical database/registry.
5-21-04: Surgical Treatment of Malignant Pleural Mesothelioma - A Review. Ruth, et al, Chest; 2003; 23:551-561.
This report shows
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Median Survival after Pleurectomy is 9 to 20 months.
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Median Survival with Extra-Pleural Pneumonectomy is 9 to 19 months.
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When comparing EPP with pleurectomy/decortication, a lower recurrence rate has been reported (10% after EPP vs 52% after pleurectomy), but EPP patients have higher rates of tumor relapses in distant sites of body.
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Mortality rate for EPP is around 5% and morbidity is between 25-50%. For
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Pleurectomy/Decortication, mortality rate is 1-2%.
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Intrapleural chemo approach has probably not shown full potential.
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The combination of complete surgery, whether EPP or P/D, along with radiation therapy seems promising but only in selected patients.
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To evaluate merits of treatment options, need to conduct a radmonized phase II clinical trial, comparing defined treatment arm with a no treatment arm.
There does not seem to be a survival benefit for patients undergoing EPP in comparison to patients undergoing pleurectomy.
2-07-02: Surgical Roles and Novel Therapies, preface by Roger Worthington
The Division of Thoracic Surgery at the Brigham and Women's Hospital in Boston Massachusetts provides diagnostic and treatment services to patients with benign and malignant neoplasms and other disorders of the lung, esophagus, mediastinum and chest wall. Their website provides complete review of services available, how to set up an appointment, whom to call, and how to prepare for surgery and rehabilitate afterwards. http://www.chestsurg.org
Comparison Articles: Read the literature providing pros and cons P/D and EPP by visiting Important Articles. This research is constantly being re-evaluated, so check back frequently.