The controversial extrapleural pneumonectomy (EPP) surgery should remain a viable option for select patients with malignant mesothelioma, despite a growing reluctance today among thoracic surgeons to recommend the procedure.
When combined with intensity modulated radiation therapy (IMRT), the EPP still can benefit some patients and improve survival times significantly, according to a recent study at the Baylor Scott & White Medical Center in Temple, Texas.
The retrospective look at 18 patients who underwent the EPP/IMRT combination found an average, overall survival rate of 38.2 months and a median relapse-free survival of 24.4 months — well above the norm for this aggressive and incurable cancer.
“This form of treatment is not dead yet and should not be buried before it’s dead,” lead author radiation oncologist Dr. Sameer Jhavar told Asbestos.com. “Our research shows this is actually a very, very good combination for a select group of patients with this disease.”
Asia-Pacific Journal of Clinical Oncology recently published the report.
The results were in contrast to the opinions of several specialists who have moved away from performing the EPP in the treatment of pleural mesothelioma.
Dr. Tom Treasure at the University College London, for example, told Asbestos.com in March that “the EPP can’t be justified anymore. One more of these is one too many.”
The EPP, which surgeons more extensively performed for mesothelioma a decade ago, involves removing the entire diseased lung, chest lining, major parts of the diaphragm, lining of the heart, lymph nodes and at least one rib.
It is one of the most extensive surgeries for any cancer.
The mesothelioma medical community once considered the EPP standard of care along with chemotherapy and radiation for pleural mesothelioma because it provided maximum resection of the disease.
However, many thoracic surgeons have cut back on the EPP because older patients often struggle coming back from such a life-changing surgery. The mortality and morbidity rates were higher than with a less aggressive surgery, meaning patients’ life expectancy was significantly shortened.
Many mesothelioma patients and their surgeons now turn to the pleurectomy/decortication (P/D) surgery, which leaves the lung intact and reduces recovery time.
“They are right, and not wrong, in saying the EPP is too much for many patients,” Jhavar said. “It all depends on the patient selection. In the right patient population, it can be done safely and effectively and provide survival hope. The key is selecting the right patients.”
The median age of the 18 patients in the Jhavar’s study was 65. They were among 104 patients with mesothelioma who were treated at the Baylor Scott & White Medical Center from 2005 to 2014.
In order to qualify for surgery, the researchers carefully screened the selected participants with extensive testing, including pulmonary function tests and a laparoscopy to ensure negative metastatic workup.
Postsurgery results were impressive. Patients didn’t experience fatal pulmonary toxicity, and results showed no toxicity recorded above grade III.
The two-, three- and five-year survival rates were 66 percent, 50 percent and 33 percent, respectively. These survival rates were among the best recorded using the combined EPP/IMRT treatment plan.
Earlier this year, cancer researchers at Kyoto University in Japan studied 21 pleural mesothelioma patients who underwent the EPP surgery and IMRT combination. The results of this study, published in Swedish medical journal Acta Oncologica, were not as impressive.
Researchers recorded a three-year survival rate of 37.5 percent and a median survival rate of 27 months after surgery. Three of the 21 participants were still alive five years after surgery.
Improved surgical techniques and more precise delivery of radiation have boosted the success of the EPP/IMRT combination. Patient selection has also improved.
Jhavar advises that only a small percentage of mesothelioma patients should be considered for the EPP surgery.
“This surgery may have fallen out of favor with some,” he said. “But it still should be considered. The surgeon selects these patients. In your eyes, an apple might be rotten, but in someone else’s eyes, you might still get the best out of that apple.”