Pleural Mesothelioma Treatment (Surgery)

In this article, we will discuss Pleural Mesothelioma Treatment (Surgery). So, let’s get started.

Surgery

Surgery is recommended for certain patients with stage I to IIIA MPM who
are medically operable. For the 2019 update (Version 1), the NCCN Panel now recommends that surgery should be considered for patients with clinical stage I to IIIA MPM; however, surgery is generally not an option for those with stage IIIB or IV MPM regardless of histology.’ It is essential that patients receive a careful assessment before surgery is performed.

Surgical resection for patients with MPM can include either 1) pleurectomy/decortication (P/D: also known as total pleurectomy, lung-sparing surgery), which is complete removal of the involved pleura and all gross tumor, or 2) extrapleural pneumonectomy (EPP), which is en-bloc resection of the involved pleura, lung, ipsilateral diaphragm, and often the pericardium.

Extended P/D refers to the resection of the diaphragm and pericardium in addition to total pleurectomy. Mediastinal nodal dissection is recommended in patients having either P/D or EPP. at least 3 nodal
stations should be obtained. The surgical goal for MPM is cytoreductive surgery to achieve macroscopic complete resection by removing all visible or palpable tumors. If macroscopic complete resection is not possible- such as patients with multiple sites of chest wall invasion- then surgery should be aborted. However, surgery should be continued- if most of the gross disease can be removed- to help with
postoperative management and if there will be a minimal impact on morbidity.

The choice of surgery for MPM is controversial, because data from
randomized controlled trials are not available. Neither EPP nor P/D will yield an R0 resection. EPP would often be required to remove all gross tumor in patients with stages Il to IIIA MPM. However, EPP is associated with higher morbidity and mortality. P/D (ie, lung-preserving surgery) is safer than EPP. A retrospective analysis (n = 663) suggested that survival was greater after P/D than after EPP, but this analysis may have been confounded by patient selection. A large meta-analysis (n = 2903) suggests that 30-day mortality is improved with P/D versus EPP; 2-year mortality was similar between the arms.

Another meta-analysis (n = 500) suggests that P/D is associated with decreased 30-day mortality and complications (especially supraventricular arrhythmia) when compared with EPP. Lung-sparing options, such as P/D, reduce the risk for perioperative mortality when compared with EPP and yield either equal or better long-term survival than non-surgical therapy in patients with more advanced disease.

A feasibility trial (Mesothelioma and Radical Surgery [MARS]) assessed
whether patients treated with induction chemotherapy would accept randomization to EPP or no surgery; 112 patients were enrolled in the trial, and 50 patients were randomized. The authors concluded that due to the observed high rate of surgical mortality, EPP was not beneficial when compared with chemotherapy treatment alone. However, these results were controversial because survival was not the primary outcome of the study, the sample size was small, and the surgical mortality was higher than expected. An Australian retrospective study (540 patients) reported that several factors yielded increased survival for select patients, including EPP, surgeon experience, and treatment with pemetrexed.

The NCCN Panel feels that P/D and EPP are reasonable surgical options that should be considered in select patients to achieve complete gross cytoreduction. Although P/D may be safer than EPP, it is not clear which operation is oncologically better. When surgery is indicated, the choice between P/D and EPP should be made based on several factors including tumor histology and distribution, stage, pulmonary reserve, surgical experience and expertise, and availability of adjuvant and intraoperative strategies. In patients who are medically operable, the decision about whether to do a P/D or an EPP may not be made until surgical exploration. P/D may be more appropriate for patients with
advanced MPM who cannot tolerate an EPP. P/D may also be useful for symptom control (eg. patients with entrapped lung syndrome, recurrent pleural effusions). The NCCN Panel does not generally recommend surgery for patients with stage IIIB to IV MPM regardless of histology; chemotherapy is recommended for these patients. In addition, surgery is
generally not recommended for patients with N2 disease unless performed at a center of expertise or in a clinical trial.

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