The most aggressive surgical procedure for pleural mesothelioma, which involves removing a lung, the pericardium and major parts of the diaphragm, should remain a viable option for select patients, despite the growing debate over its usefulness.
A recently completed review of an extrapleural pneumonectomy (EPP) at Brigham and Women’s Hospital in Boston shows the procedure will continue to be an effective tool in multimodal treatment.
“This was a confirmation that in high-volume centers, the operation can be done safely, and that many patients will do fine under the right circumstance,” assistant professor of surgery at Harvard Medical School, Dr. William Richards, told Asbestos.com. “The take home message is that, despite the controversy, if what you need is a pneumonectomy [lung removal] for complete resection, it’s a good option, when the alternatives are doing nothing or getting chemotherapy.”
Richards co-authored the study published in the October issue of Annals of Surgery with thoracic surgeons Drs. David Sugarbaker and Raphael Bueno.
Sugarbaker, who helped pioneer the EPP, recently left Brigham and Women’s Hospital after more than two decades to direct the new Lung Institute at the Baylor College of Medicine. Bueno replaced Sugarbaker as the thoracic surgery chief at Brigham and Women’s.
Disputing Earlier MARS Study
One of the reasons for conducting the Brigham and Women’s study was to reaffirm the value of the EPP after the earlier Mesothelioma and Radical Surgery (MARS) study in the U.K. that showed no survival benefit to the radical EPP, and suggested it should no longer be performed anywhere.
The MARS study had a much smaller number of patients involved. The EPP is no longer performed in some European countries, and the number of EPP surgeries in the U.S. has dropped in recent years.
Renowned mesothelioma specialist Dr. Robert Cameron, thoracic surgeon at the Pacific Heart Lung & Blood Institute, also has spoken out against doing the EPP, preferring the lung-sparing pleurectomy/decortication (P/D) surgery.
Critics of the EPP contend the risks of such a major surgery outweigh any benefits.
The Brigham and Women’s study offered a different view. The authors of the study also called for revising the lymph node staging system, which could lead to better selection of patients who could benefit from the surgery.
The study examined 529 patients with the epithelioid type of mesothelioma who underwent an EPP between 1988 and 2011. Part of the conclusion was that lymph node status in patients was directly related to overall survival rates.
Five percent of those patients died within 30 days of the surgery, but 4 percent of them lived for 10 years or more. The median overall survival was 18 months. Overall, 28 percent of the EPP patients lived at least three years, and 14 percent lived for five years or more after surgery.
Median survival of patients who do not undergo surgery, by choice or because of advanced disease, poor overall health or advanced age, is 7-12 months, the study shows.
“This study indicates that if you have the surgery in a center that does a lot of them, it’s not the gloom and doom scenario that you may hear about with high operative mortality and short survival,” Richards said. “The five- and 10-year survival rates are significant.”
Under Sugarbaker’s guidance, Brigham and Women’s has been a long-time leader in mesothelioma care. During the study period, there were 1,258 major mesothelioma surgeries at the hospital. Within that total were 832 EPPs, including 528 with the epithelioid sub-type. The remaining cases were P/D or partial pleurectomy surgeries.
Revision to Staging of Lymph Nodes
Although the overall median survival rate was just 18 months, it was 26 months for those who had no lymph node involvement. It was 17 and 16 months, respectively, for those with metastasis in lymph node stations 1 and 2. The median survival was just seven months for those with lymph node involvement in station 3, the most distant from the diseased lung.
The preoperative surgical staging changed throughout the study period, resulting in improved survival rates for patients in the later years. Although lymph node involvement has been part of the staging process, the study’s authors have encouraged a revision in the future.
“We should be looking at ways in which the staging system might be modified to separate patients better for treatment decisions or clinical trial eligibility based on lymph node status, tumor volume, histologic subtype and other prognostic factors.”