Dr. Pietro Bertoglio and his colleagues at the University Hospital of Pisa stopped performing the aggressive extrapleural pneumonectomy (EPP) surgery for mesothelioma more than a decade ago.
They believe it’s long overdue for everyone else to do the same and instead use the less-debilitating pleurectomy/decortication (P/D) procedure.
The Journal of Thoracic and Cardiovascular Surgery recently published the University Hospital of Pisa’s 10-year experience using P/D and hyperthermic intrathoracic chemotherapy (HITHOC).
Two editorial commentaries from thoracic surgeons in the U.S. accompanied the study from Italy, supporting it to varying degrees.
“I’m sure this [P/D surgery] is the way to go now with mesothelioma,” Bertoglio told Asbestos.com. “It just gives the patient the better chance.”
Two Contrasting Mesothelioma Surgeries
EPP was commonly used by mesothelioma specialists two decades ago, but prevalence of the approach has fallen significantly.
The surgery involves removing an entire diseased lung, the lining around it, much of the diaphragm and the lining of the heart. EPP is one of the most aggressive surgeries for any cancer, and its mortality and morbidity rates are considerably high.
P/D, by comparison, leaves the lung, diaphragm and heart lining intact.
The procedure removes the lining around the lung and any diseased tissue. It also removes any visible tumor cells throughout the chest cavity, including those on the lung.
P/D is a much more detailed, meticulous procedure, but less traumatic to the patient.
“We know, and everyone knows, that surgery is not a definitive treatment for mesothelioma,” Bertoglio said. “You need a multidisciplinary approach. Surgery is just one step. Not only do we want to preserve as much of the anatomical structure as we can, but also the respiratory function.”
P/D Results Were Good
The Italian study included 49 patients in a 10-year period.
All received P/D and HITHOC, a way of delivering chemotherapy directly to the chest cavity. Patients also were able to finish at least three cycles of adjuvant chemotherapy, and many received adjuvant radiation therapy.
The median survival rate was 22 months. The one-, two- and five-year survival rates were 79.6 percent, 45.7 percent and 9.9 percent, respectively.
The median age of the patients was 68 years, and most were treated during cancer stage 2 or 3.
There were no cases of mortality in the first 90 days.
“More invasive procedures such as the EPP do not have any survival benefit compared with P/D,” the study authors wrote. “They have a high mortality rate, and one third of the patients are generally unable to complete the multimodality treatment.”
US Mesothelioma Specialists Respond
Thoracic surgeon Dr. Andrea Wolf at Mount Sinai Hospital in New York supported the study’s premise.
“The study confirms increasing consensus that lung preservation, ie, P/D, is paramount in MPM [malignant pleural mesothelioma],” Wolf wrote in an accompanying editorial. “The key message is the report’s biggest strength — in MPM surgery, less is more.”
In 2017, Wolf co-authored a report in Annals of Translational Medicine that examined the impact of different surgeries on quality of life after a diagnosis of mesothelioma.
The study showed P/D was superior to EPP in lung-function parameters, physical and social functioning and continued symptoms.
“We’re finding that patients just do better in terms of survival and in terms of quality of life,” Wolf told Asbestos.com.
Thoracic surgeon Dr. Steven Milman at the Warren Alpert Medical School of Brown University emphasized instances where EPP should be used.
“Until high-level data are available to indicate otherwise, the EPP should not be entirely abandoned,” Milman wrote in his editorial. “Circumstances may arise warranting its consideration, such as a young healthy patient with extensive visceral pleural and parenchyma disease for which complete macroscopic resection can only be achieved by pneumonectomy.”
A Shrinking Space for EPP
While many thoracic surgeons moved away from using EPP, others believe there still is a role for the procedure.
A 2017 study at the Scott & White Medical Center in Temple, Texas, showed impressive survival rates for patients having the procedure.
During a 10-year period with 104 patients being treated for mesothelioma, 18 underwent an EPP with follow-up intensity modulated radiation therapy (IMRT).
The two-, three- and five-year survival rates were 66 percent, 50 percent and 33 percent, respectively.
The average overall survival rate of 38.2 months was among the best recorded for that procedure.
“It all depends on the patient selection. In the right patient population, [EPP] can be done safely and effectively and provide survival hope,” radiation oncologist Dr. Sameer Jhavar said. “The key is selecting the right patients.”
While Bertoglio and his staff are committed to P/D as the only major surgical option to offer, he understands why others might not totally agree.
“There might be some very select cases where the EPP would be beneficial,” Bertoglio said. “But very select cases, very rare cases and very personalized cases. That might be true, but for the largest number of surgical cases of mesothelioma, no, I don’t think so.”