Surgery for malignant pleural mesothelioma: Why, when and what?

doi:10.1016/j.lungcan.2014.01.021

Lung Cancer

Volume 84, Issue 2, May 2014, Pages 103-109

https://doi.org/10.1016/j.lungcan.2014.01.021 Get rights and content

Abstract

Malignant pleural mesothelioma is a fatal cancer developing in the pleural cavity, linked to asbestos exposure. Various therapies have been tried in the past 50 years including surgery, radiotherapy, chemotherapy, immunotherapy and more recently, targeted therapy. Radical surgery remains controversial in malignant pleural mesothelioma and two procedures have been offered in the past to obtain maximal cytoreduction: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). Despite growing evidence that EPP might be detrimental, many believe that radical surgery should still be part of multimodality therapy in patients with malignant pleural mesothelioma. Recent evidence suggests that P/D is well tolerated and produces low mortality and morbidity. The role of adjuvant intrapleural therapies remains to be determined and evaluated in large prospective trials. Pleurectomy/decortication does not jeopardize the chance of having chemotherapy, or chemoradiotherapy either. Many now believe that it should be the default procedure in multimodality regimens. However, this remains to be proven in a large randomized trial. Palliative surgery still has an important role to play in mesothelioma, in establishing or refining diagnosis and in controlling symptoms and improving quality of life in many patients whose life expectancy is limited. Recent progress in molecular analyses and biomarkers should help with patient selection for surgery, immunotherapy and systemic therapies in the near future.

Section snippets

Radical surgery

No other field as radical surgery for mesothelioma has attracted so much controversy in the thoracic community [17]. Two procedures have been offered to resect pleural mesotheliomas: extrapleural pneumonectomy which involves en-bloc resection of the all lung (pneumonectomy) with surrounding pleura, ipsilateral hemi-diaphragm and ipsilateral pericardium (Fig. 1), and pleurectomy which involves a resection of the pleural tissues only (Fig. 2). Although the different steps involved in EPP (en-bloc

Palliative surgery

Although an ultrasound or CT-guided biopsy can be performed in most patients with solid-type presentation, a thoracoscopic/VATS procedure is generally offered to patients presenting with a significant pleural effusion, especially if fluid re-accumulates rapidly or if pleural cytology is not conclusive. Pleural cytology is not extremely reliable in MPM and it is cytopathologist-dependent. Ideally, in patients qualifying for multimodality therapy, a formal pleural biopsy should be obtained to

Conclusion

Despite growing evidence that EPP might be detrimental, we strongly believe that radical surgery should still be part of multimodality therapy in patients with malignant pleural mesothelioma. Recent evidence suggest that P/D is well tolerated and produces low mortality and morbidity. The role of adjuvant intrapleural therapies remains to be determined and evaluated in large prospective trials. Pleurectomy/decortication does not jeopardize the chance of having chemotherapy, or chemoradiotherapy