Pleural mesothelioma patients considering surgery should be aware of the latest comparison study, detailing the mortality and morbidity rates of aggressive extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D).
Despite advances in all therapies that make up the standard of care for mesothelioma, the EPP surgery still carries stubbornly high mortality and morbidity rates when compared to the less aggressive, but often equally effective, P/D surgery.
The Journal of Thoracic and Cardiovascular Surgery in April published the findings of a three-year, multicenter study of surgical morbidity and mortality in both procedures.
The significant difference in the rates continues to fuel the simmering debate over which procedure is most advantageous to patients.
Both procedures involve removing the thin lining around the lungs, which is where the cancer typically begins spreading. The EPP also involves removing an entire diseased lung, the lining around the heart and major parts of the diaphragm to hopefully remove as much of the disease as possible.
The P/D involves removing the entire lining, plus meticulously removing any tumors visible on the lung and throughout the chest cavity. The patient retains both lungs.
“I don’t think there were any big surprises in the study, but rather what we suspected all along. It confirmed some of the feelings we already had,” renowned mesothelioma surgeon Wickii Vigneswaran, M.D., at the University of Chicago Medical Center, told Asbestos.com. “This is a disease in which there still is no great treatment yet. We’re striving for that.”
Vigneswaran and the University of Chicago have been leaders in developing more advanced diagnostics, better therapies and improved surgical outcomes throughout the past decade, but the study reiterated how much work must still be done. There is no definitive cure for mesothelioma. The majority of patients live less than two years after diagnosis.
Wide Range of Patients Studied
The study included 225 pleural mesothelioma patients treated from 2009 to 2011, who were part of the Society of Thoracic Surgeons General Thoracic Surgery Database. There were 130 P/D patients and 95 EPP patients, spanning a wide variety of medical centers, from high volume (more than five procedures annually) to low volume (one annually).
There were 24 different centers doing at least one P/D and 37 centers that performed at least one EPP. Only 13 centers did both during the study period.
The EPP had a post-operative mortality (death within 30 days) of 10.5 percent, compared to just 3.1 percent with the P/D. The EPP had a major morbidity (complication) rate of 24.2 percent compared to just 3.8 percent with the P/D. An unexpected return to the operating room occurred in 9.5 percent of the EPP patients, but only 1.5 percent of the P/D patients.
The study also accentuated the statistical advantage patients receive when having surgery at a higher volume center. The mortality rate after the EPP was just 6.5 percent at the high-volume centers, but 12.5 percent at the lower volume centers. There also was a higher rate of acute respiratory distress syndrome (ARDS) at the lower volume centers.
Patients Should Find High-Volume Center
“It’s so important for a patient to seek out a center with expertise with this particular disease,” said Vigneswaran, one of seven authors of the study. “It’s not just the surgeon but the whole team, from the tumor board discussing the case and the best way to handle it, to the nursing staff and post-operative care. Experience is critical.”
Among surgeons across the country, there are proponents of each procedure, although the long-term survival statistics and studies have been mixed. Survival rates often depend on the stage of the disease when diagnosed, the histological type of mesothelioma, the overall health and age of the patient and the surgical selection process. Less than half of mesothelioma patients are selected for major surgery. Some centers are more selective about who is eligible.
Proponents of Each Type of Surgery
Some studies conclude that EPP should not be done under any circumstances.
Surgeon Robert Cameron, M.D., a mesothelioma specialist and director of thoracic surgery at the UCLA Medical Center, has lobbied for years to eliminate the EPP surgery, believing that patients are better served with the lung-sparing P/D surgery.
Meanwhile, surgeon David Sugarbaker, M.D., a mesothelioma specialist who recently became chief of general thoracic surgery at the Baylor College of Medicine, remains a strong proponent of the EPP procedure he helped pioneer.
Vigneswaran, like the majority of mesothelioma specialists, believes there is a place for both types of surgery. The key, he said, is the careful selection process.
“It has to be tailored to the patient,” he said. “We are very selective in who is offered the EPP because it is such a complex procedure. It’s a big decision for everyone. We have had good results with both procedures. For a patent, it would not be wise to have it (EPP) done where they are doing only one or two a year. That, you can say for sure.”