The simmering debate about which surgical treatment is preferred for malignant pleural mesothelioma has become considerably more one-sided lately, further addressed by surgeon Loic Lang-Lazdunski, M.D., in the latest report by the International Association for the Study of Lung Cancer.
The less radical pleurectomy and decortication (P/D) has proven to be more successful and safer in many ways than the extrapleural pnemonectomy (EPP), which once was considered the standard of care and continues to be used by some American surgeons.
The study was published in the April 2012 issue of Journal of Thoracic Oncology.
“The results are there. My view is clear: EPP should be abandoned in malignant pleural mesothelioma,” Lang-Luzdunski told Asbestos.com.
EPP Shows Higher Mortality and Morbidity Rate
EPP involves a removal of the entire diseased lung, lung lining, part of the membrane covering the heart and part of the diaphragm.
P/D, which is less extensive but more detailed, involves partial removal of the lining around the lung, potentially part of the lung, and potentially part of the diaphragm.
According to this latest study, EPP resulted in higher mortality and morbidity than P/D, which had a better survival rate.
“The results of the current study provide additional data that should lead us to consider P/D in all trials of treatment for MPM,” wrote Michael Weyant, M.D., thoracic surgeon and professor at the University of Colorado who wrote an accompanying editorial in the Journal of Thoracic Oncology.
Weyant did not call for abandoning all EPP procedures as others have suggested leaving open the possibility that there may be some patient subsets “where the potential reward outweighs the risks of the procedure.”
Renowned Mesothelioma Surgeon Prefers P/D
Robert Cameron, M.D., director of the UCLA Mesothelioma Comprehensive Research Program, has been America’s most outspoken critic of EPP.
As a surgeon, Cameron has performed P/D procedures for 20 years. He is the catalyst behind the upcoming second annual International Symposium on Lung-Sparing Therapies for Malignant Pleural Mesothelioma.
“Clearly, it is best for the patient to treat mesothelioma as a chronic illness while preserving the function of both lungs,” Cameron said recently.
The study done by Lang-Lazdunski included 76 patients spanning eight years (2004-2011). Twenty two patients underwent EPP and 54 underwent P/Ds.
The 30-day mortality rate was 4.5 percent in the EPP group and 0 percent in the P/D group. Within each group, 15 patients experienced post-surgery complications, which translated into 68 percent of the EPP group but only 27 percent of the P/D group.
Significant Increase in Survival Rate
There was no obvious difference in age, gender, histology, pathologic stage and nodal status between the two groups.
Most importantly, the survival rate was significantly better in the P/D group than the EPP group, respectively. Other key statistics:
- Median survival was 23 months vs. 12.8 months;
- Two-year survival was 49 percent vs. 18.2 percent;
- And five-year survival was 30.1 percent vs. 9 percent for the EPP group.
“Is it [EPP] worth the pain and reduction in quality of life?” Lang-Lazdunski told Asbestos.com. “My answer is no, especially when you consider the risks and the fact that most patients cannot receive more treatment if they relapse.”
Lang-Lazdunski works at Kings College London-Division of Cancer Studies. He stopped performing EPP in 2008.
“We propose that P/D becomes the standard surgical procedure offered as part of a multi-modality therapy in malignant pleural mesothelioma,” Lang-Lazdunski wrote. “In our experience, P/D…was superior to EPP with adjuvant radiotherapy.”