The much-debated and extremely aggressive extrapleural pneumonectomy (EPP) surgery still should play a prominent role in the management of mesothelioma, according to a recent U.K. study.
The study reopened the simmering controversy over the value of the EPP by contradicting the conclusions of previous research that prompted some specialists to stop doing the surgery and others to dramatically reduce the number of procedures.
The EPP involves the removal of an entire lung, the lining surrounding the lung and heart, along with major parts of the diaphragm, all in a curative attempt to remove as much cancer as possible.
Critics of the EPP have argued the risks are not worth the rewards, and that the disease can be better managed in less aggressive ways. They point to the much-discussed Mesothelioma and Radical Surgery (MARS) trial completed in 2011, which cited 112 patients from 12 different hospitals throughout the U.K. The MARS conclusion was that benefits of the EPP were negligible, while quality of life was diminished.
“One more of those surgeries would be one too many,” surgeon and researcher Tom Treasure, University College of London, told Asbestos.com shortly after the MARS trial. “That surgery can be stopped now without a loss.”
Since the MARS trial, very few EPP surgeries have been done in the U.K. They are done more often in the U.S., although specialists are being much more selective with their surgical candidates.
Some Lobbying Against EPP
Robert Cameron, M.D., renowned thoracic surgeon at the Pacific Meso Center and the UCLA Medical Center, has lobbied vehemently against the EPP for many years, preferring the lung-sparing pleurectomy/decortication surgery.
Renowned specialist David Sugarbaker, M.D., who is leaving Brigham and Women’s Hospital in Boston to start at a new mesothelioma program at the Baylor College of Medicine, continues to promote the benefits of the EPP.
“We have demonstrated improved short- and long-term outcomes with EPP in the present study,” researchers wrote in the Journal of Thoracic and Cardiovascular Surgery (Jan. 15, 2014). “It is our contention that radical surgery, including EPP in the management of MPM [malignant pleural mesothelioma] should not be discouraged on the basis of a single controversial feasibility study (MARS trial).”
The study included 30 malignant pleural mesothelioma patients who had undergone EPP surgery at Castle Hill Hospital in the U.K. There were no in-hospital or under-30 day deaths. The long-term survival analysis included 35 percent living after three years and 31 percent more than four years.
Results Have Been Good
Two patients lived more than seven years. And two more were still alive after six years when the study data concluded in February 2013. The overall median survival was 20 months, but it increased to 47.5 months for patients who completed a trimodality treatment regimen that included chemotherapy and radiation.
Survival at six, 12 and 18 months was 80 percent, 65 percent and 55 percent, respectively. The survival in the MARS trial, for the same respective time periods, was 65 percent, 52 percent and 34 percent.
“The EPP has a definite role in the management of malignant pleural mesothelioma,” Syed Qadri, a cardiothoracic surgeon at Castle Hill Hospital in the U.K., told Asbestos.com. “But it is not a procedure for every stage of disease, or every patient. It has shown encouraging results in selective groups of patients.”
The researchers also pointed out that the operative mortality of EPP has decreased, from 31 percent in 1976 to 3.4 percent in 2011. Of the 30 patients who were part of the study, four died between 30-60 days after the surgery.
Surgery Patients Must Be Selected Well
The report emphasized certain characteristics that made EPP surgery considerably more effective. Prolonged survival was associated with epithelioid mesothelioma, a right-sided pneumonectomy, being younger than 65 and negative extrapleural lymph nodes.
In epithelioid mesothelioma, there was a 44 percent survival rate of three years or more. With the biphasic mesothelioma group, none survived 18 months. Those under 65 had a median survival rate of 27 months, compared to a 12-month survival rate for those over 65. The three-year survival was 41 percent for the younger group, but only 24 percent for the older group.
“The MARS trial definitely effected [negatively] the management of mesothelioma worldwide,” Qadri said. “But we have [EPP] patients who still are alive after eight years. There are surgeons in the United States who believe in EPP, as well. We believe the EPP can be performed safely and effectively as part of a trimodality management.”