Renowned thoracic surgeon Raja Flores, M.D., isn’t ready to abandon the aggressive and once-preferred extrapleural pneumonectomy procedure for patients with mesothelioma, but now he is convinced there is a better surgical option.
Flores, chairman of the department of thoracic surgery at Mount Sinai Hospital in New York, is part of a growing number of mesothelioma specialists around the world who believe the more precise, lung-sparing pleurectomy/decortication is a better choice for most patients.
Flores joined Emanuela Taioli, M.D., Ph.D., of Hofstra University School of Medicine; and Andrea Wolf, M.D., of Mount Sinai Hospital, in publishing the largest study comparing the extrapleural pneumonectomy (EPP) with the pleurectomy/decortication (P/D).
The most startling result of the analysis was an almost three-time higher rate of death within the first 30 days after the EPP surgery.
“The evidence now is pointing to the P/D as the surgery that serves the patient best,” Flores told Asbestos.com. “I have patients who are long-term survivors from both procedures I’ve done, but I’d say the pleurectomy is the better choice now most of the time.”
The EPP involves removal of the entire diseased lung, the lining surrounding both the lung and heart and major parts of the diaphragm. The P/D, which is less extensive, removes only the visible tumors on the lung, the entire lining around it and potentially parts of the diaphragm.
“The EPP is a much bigger hit to the patient. If you’re going to do something of that magnitude, you want to see a big difference in survival from that procedure,” Flores said. “But I think this analysis shows that you’re not getting the grand slam you wanted. You’re barely getting the single.”
The analysis included a compilation of 24 distinct data sets from earlier studies that included 1,512 EPP patients and 1,391 P/D patients. The surgeries were performed from 1990 to 2014. It ended with a conclusion that the P/D surgery should be preferred when technically feasible.
Although the mortality difference between the two was dramatic in the short term, both the two-year and long-term survival rates were similar. There was a 4.5 percent mortality rate within the first 30 days for the EPP, but only 1.7 percent with the P/D.
Patients undergoing the EPP also had more post-operative complications at various stages than patients who had the P/D.
The decision on which option to use, many times, is not definitively made until the surgery has begun because various scans and pre-surgery tests often underestimate the amount of disease that is present.
There are thoracic surgeons who have called for the complete elimination of the EPP surgery for mesothelioma patients, believing it does more harm than good for any patient. Flores, though, has not gone that far.
“We’re much more selective on the ones we do. There still are a few situations where the EPP is better,” he said. “I don’t believe you should say the procedure never should be done. You still can see patients where it is the best option, but not very often anymore.”
Although the quality-of-life issue didn’t show up in any statistical analysis of the two surgeries, Flores believes it should play a major role in any decision being made by a patient.
Although the EPP usually produces a more complete cancer cell resection, it also puts a more traumatic strain on a patient and requires a longer recovery period.
“You’re going to have a better quality of life with two lungs than with one, that’s pretty much a given,” Flores said. “But the most important thing is to get out all the tumor cells.”
Over the last decade, Flores has emerged as the most acclaimed mesothelioma specialist in New York. Peers and patients tout both his surgical and intrapersonal skills.
He was elevated to chief of thoracic surgery in 2010, making the treatment of mesothelioma a priority at Mount Sinai.
“Often the surgery can be an intraoperative decision,” he said. “It’s critical to have someone with experience doing it. A patient needs to have someone who knows the way this [mesothelioma] tumor lives and breathes.”