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Current Surgical Treatment Of Malignant Pleural Mesothelioma.

Koji Chihara
Published 2018 · Medicine

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Malignant pleural mesothelioma (MPM) is an aggressive disease that has a poor prognosis if left untreated. Multimodal therapies including surgery, chemotherapy, radiation therapy, and immunotherapy have been tried for several decades. Aggressive surgical resection by extra-pleural pneumonectomy (EPP) that aims at macroscopic complete resection (MCR) of the tumor with en bloc resection of the lung, parietal and visceral pleurae, diaphragm, and pericardium has been performed by several groups [1–3] since the first report by Butchart et al. [4]. In these studies, for epithelioid type mesothelioma without nodal metastasis, completion of trimodal therapy with cisplatinbased chemotherapy followed by EPP and radiation therapy was shown to predict improved survival. EPP is a radical procedure; complications following pneumonectomy for cancer include supraventricular arrhythmias, acute respiratory distress syndrome, bronchopleural fistula, and empyema. Besides, cardiac or diaphragmatic herniation due to dehiscence of an artificial patch to cover the defect of the pericardium or diaphragm may occur during the early postoperative period after EPP and can be fatal. Better patient selection, improved anesthetic management, operative techniques, and postoperative intensive care over the years has reduced mortality following EPP to 2–7% in high volume centers [1–3]. Lung-sparing surgery by removal of the parietal and visceral pleura (pleurectomy/decortication, P/D), leaving the lung intact, has emerged [5–7]. Any tumor invading the pericardium or the diaphragm is resected and reconstructed with artificial patches as in EPP. This requires substantial experience with EPP and considerable skill; tumor laden parietal and visceral pleurae are removed while avoiding injury to the lung parenchyma. Massive hemorrhage may occur during this procedure. A prolonged air leak from breaches of the lung parenchyma and mucous plugging with atelectasis are unique complications after P/D. These are serious complications, but may be effectively managed by chest tube drainage or bronchial toilet [8]. The optimal surgical management of MPM remains controversial. No convincing data support the superiority of one procedure over the other; no randomized controlled studies have compared EPP with P/D. However, most studies suggest that P/D is associated with better short-term outcomes than EPP in terms of perioperative morbidity and mortality. A systematic review and meta-analysis of 513 patients who underwent P/D and 632 who underwent EPP showed lower mortality (2.9% vs 6.8%) and morbidity (28% vs 62%) with P/D [9]. Although EPP and P/D can achieve MCR, local recurrence rate is substantially high [10]. Thus, radiation therapy to prevent local recurrence has been performed [11,12]. Hemithoracic radiation is more feasible after EPP; use of radiotherapy is limited after P/D due to the risk of lung toxicity. Hence, P/D has been associated with a higher incidence of local recurrence compared to EPP [8]. However, recent reports show that with increasing experience, intensity-modulated radiation therapy (IMR), can be delivered safely after both EPP and P/D [13]. Flores et al. reported improved cumulative survival for patients with early stage mesothelioma with curative-intent P/D compared with EPP; EPP conferred higher cumulative survival in patients with late-stage disease [6]. In the recent US national cancer database report on the operative technique for MPM, 1036 patients (79%) underwent P/D while 271 patients underwent EPP. Patients who had P/D were older; no differences were observed in overall survival [14]. The advantage of P/D is that the lung is preserved and remains functional. It may be preferred for the elderly and those with poor cardio-pulmonary reserve for whom EPP may not be feasible [15]. Recent developments in surgical technique may represent a paradigm shift in the treatment of MPM.
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