Belgian EPP Study Shows Mesothelioma Surgery Extends Survival
March 4, 2019
Using proper patient selection, doctors in Leuven, Belgium, are extending mesothelioma survival times significantly with the controversial extrapleural pneumonectomy surgery.
Despite a growing reluctance to perform the surgery within the United States and throughout much of Europe, mesothelioma specialists at University Hospitals KU Leuven have continued performing it with great success.
Their 2018 single-center study of the extrapleural pneumonectomy (EPP) for pleural mesothelioma produced a 33.2-month median survival and a 24.2 percent five-year survival.
“With our dedicated team, a patient can do well with this surgery,” Dr. Anna Frick, department of thoracic surgery and lead author of the study, told The Mesothelioma Center at Asbestos.com. “Although it is a very demanding surgery — and it is not for every patient — it can be done with much success.”
The European Journal of Cardio-Thoracic Surgery in December 2018 published the study that started with 97 pleural mesothelioma patients who qualified for the EPP as part of a multidisciplinary treatment regimen between 2003 and 2014.
Of the 56 patients who underwent the EPP surgery, three have survived 10 years or more. Another four, who are still alive today after more than five years, have the potential to reach the 10-year mark.
“There is an advantage with the EPP for mesothelioma patients,” Frick said. “We believe that here.”
Patient Selection Critical to Success
The EPP is one of the most aggressive surgeries for any cancer. It involves removing an entire lung, the lining around it, parts of the diaphragm, the heart lining and nearby lymph nodes. The procedure removes the maximum amount of cancerous tissue.
Frick estimates the center still averages five to 10 EPP surgeries annually for pleural mesothelioma. She also emphasizes the importance of patient selection and the experience of a high-volume center as reasons for their success.
“Not only the surgery counts, but the preop and postop experience is so important,” she said. “If you don’t know how to treat patients after the surgery, then you’re doing the surgery for nothing. Everyone on the team has to have experience.”
P/D Is Preferred Surgery
Many specialty centers throughout the U.S. have stopped or significantly reduced the number of EPP surgeries they perform. The consensus: The less aggressive, lung-sparing pleurectomy/decortication is the wiser choice.
Much of the opposition to the procedure stems from the much-debated Mesothelioma and Radical Surgery (MARS) trial completed in 2011 in the United Kingdom.
The MARS trial was the first major study that concluded the EPP carries a diminished quality of life, high mortality and morbidity rates, and no significant survival benefits. Many specialty centers across Europe stopped the procedure.
Well-respected mesothelioma specialists Dr. Robert Cameron, a thoracic surgeon at the UCLA Medical Center, and Dr. Tom Treasure, a former thoracic surgeon at University College London, are outspoken critics of the procedure.
“The MARS study needed more patients to conclude what it concluded. That it automatically had a high mortality rate,” Frick said. “I disagree with that.”
Acceptable Surgical Mortality Rate
None of the 56 surgical patients in the Belgian study died within the first 30 days. Two of the 56 died within 90 days.
In contrast to the recent study results, the average patient typically lives only 6-18 months after a diagnosis of pleural mesothelioma, which is caused by a long-ago exposure to asbestos.
According to the Belgian National Cancer Registry, the one-year survival rate for pleural mesothelioma is less than 50 percent. The five-year survival rate is 6.5 percent.
Of the 56 patients in the study who underwent the surgery, 47 completed the entire combined modality treatment. It included chemotherapy before surgery and hemithoracic radiotherapy after surgery.
Although the trend among specialists has moved away from the EPP, the Belgian study isn’t alone in its continued support of the procedure.
EPP Part of Sugarbaker Legacy
Thoracic surgeon Dr. David Sugarbaker, who died in 2018, first popularized the EPP surgery two decades ago, and he proved how well it could work with many of his patients.
Sissy Hoffman of Georgia is America’s longest-living pleural mesothelioma survivor and a testament to Sugarbaker’s legacy. She underwent the EPP in 1996 and still is thriving today.
Tim Crisler, also from Georgia, is a 17-year pleural mesothelioma survivor, and another example of an EPP patient who still lives an active life today.
Both mesothelioma survivors are examples of well-selected patients, which was imperative for the most recent study.
Of those in the study who underwent the EPP surgery, 82.1 percent had the epithelioid subtype of mesothelioma, which is the least difficult to treat. The average age was just 57, considerably younger than the average mesothelioma patient.
During the 11-year study, 197 patients with pleural mesothelioma came before the University Hospital’s multidisciplinary tumor board review.
A total of 100 did not fit the eligibility criteria for multidisciplinary treatment that included surgery. The main reasons for exclusion: Advanced stage disease and age.
From the 97 remaining, 21 were dropped after induction chemotherapy. Another 20 were eliminated after an exploratory thoracotomy revealed unresectable disease, leaving 56 eligible for the EPP.
“Careful patient selection is of the highest importance,” the study concluded. “Our results demonstrated that patients with operable MPM had an acceptable survival and surgical mortality rate.”