Aggressive pleurectomy/decortication surgery, while often recommended, will cause a significant decrease in pulmonary function with early-stage mesothelioma patients whose symptoms were previously minimal.
More symptomatic patients with advanced disease will experience an improved quality of life and a preservation of their current pulmonary status after the same surgery.
Those findings were reported in a study from the Department of Surgery, Division of Oncology at the University of Chicago Medical Center, raising questions about aggressive surgery for the early stages of mesothelioma.
“Some of the results might be a little unexpected,” renowned cardiothoracic surgeon Dr. Wickii Vigneswaran, told asbestos.com. “They gave us something to look closer at. They didn’t change our thinking.”
The study was published last month in the Annals of Thoracic Surgery.
Performance Status Is Key
The P/D surgery involves the removal of the pleural lining around the lungs, as well as any visible tumors on the lungs or surrounding areas. The surgery also often involves partial or complete resection of the diaphragm, which is rebuilt with prosthetics.
The study included 36 mesothelioma patients at the University of Chicago Cancer Center, all of whom had the P/D surgery performed by Vigneswaran, one of the country’s leading thoracic surgeons. He also is well known for his expertise in thoracic organ transplants.
There were 17 patients with a performance status (PS) of 0 at the time of surgery, meaning they had only minimal symptoms and still were fully active. There were 19 patients with a PS status of 1 or 2. Those patients had obvious but varying degrees of symptoms, yet could still take care of themselves.
According to the authors, this was the first study that measured how the P/D surgery affected both pulmonary function and health-related quality of life.
There’s Still No Reason to Wait
While early-stage patients initially lost pulmonary function after the surgery, Vigneswaran still believes the surgery leads to longer survival when the disease is diagnosed and treated as soon as possible.
“It’s still not a good idea to wait [to have the surgery]” Vigneswaran said. “Tumor burden is still a good predictor of survival. The more tumors you have at time of surgery, the worse the outcome will be long-term.”
Most of the patients with PS status of 0 (minimal symptoms) at time of surgery already had undergone palliative treatments to remove fluid, alleviating breathing problems and other symptoms.
Patients all were measured pre-operatively and six months post-operatively for the pulmonary function tests. Their quality of life was evaluated twice: once at 4-5 months and then at 7-8 months after the operation. Most of the patients received adjuvant chemotherapy after surgery.
The median age was 70. The PS 0 group started with better quality of life measurements before surgery. The PS 1 and PS 2 groups all showed significant improvements at both benchmarks.
Rebuilding the Diaphragm Plays a Role
The surgery is designed to restore lung expansion by removing the restrictive tumors from the lung and the chest wall. For the PS 0 patients, though, the decline in the pulmonary function likely stemmed from the accompanying diaphragm resection, even with the lung function improved, according to Vigneswaran.
“It’s difficult to make [pulmonary function] better, if there are no symptoms,” he said. “The thinking now is to look closer at the role of the diaphragm resection, and the role it plays in the surgery.”
The study also points out the decrease in pulmonary function for some patients is minimal compared with the decrease that comes with the even more aggressive extrapleural pneumonectomy (EPP) surgery, which involves removing the entire lung.
“Overall, the quality of life is better after the surgery,” Vigneswaran said.