Current Treatment of Mesothelioma: Extrapleural Pneumonectomy Versus Pleurectomy/Decortication

Key points

The case for surgery in treatment of malignant pleural mesothelioma

Although there is no defined standard treatment for MPM, most studies in the literature support the use of curative intent surgery in the context of multimodality therapy.10, 11, 12, 13 Surgical resection is offered to more than 40% of MPM patients seen at large tertiary referral centers.¹⁴ In the general population, however, fewer patients are offered cancer-directed surgery. Flores and colleagues¹⁵ reported that cancer-directed surgery was performed in only 22% of 5937 patients with MPM in

Data comparing extrapleural pneumonectomy with pleurectomy decortication

P/D is associated with better short-term outcomes than EPP in the form of perioperative morbidity and mortality. One study evaluating these results in the Society of Thoracic Surgeons Database found higher rates of acute respiratory distress syndrome, reintubation, unexpected reoperation, sepsis, and mortality after EPP compared with P/D.⁴⁴

The high risk of EPP without clear demonstration of survival benefit has led many clinicians to advocate against EPP.⁴⁵ The Mesothelioma and Radical Surgery

Summary

Despite decades of application in practice, the role of surgery in the treatment of MPM is not considered standard and there is certainly no procedure of choice. Although it does not seem that a randomized trial can be done to shed light on this issue, the evidence is clear that P/D is better tolerated by patients and suggests that survival is no worse. Because recurrence patterns are generally local regardless of operation, leaving the patient with 2 lungs after first surgery may well improve