Some Mesothelioma Patients May Benefit from Second Radical Surgery

As overwhelming as major surgery for malignant pleural mesothelioma can be, there is a small cohort of patients who still would benefit from a second aggressive operation following the almost inevitable cancer recurrence.

There are tangible returns, according to a recent study. Extended survival and better quality of life still can be attained.

“A second surgery for mesothelioma is not out of the question,” thoracic surgeon Dr. Hany Hasan Elsayed, Faculty of Medicine, Ain Shams University in Cairo, Egypt, told The Mesothelioma Center at Asbestos.com. “I’m not saying it’s common – or should be done for all – but with the right criteria, there can be benefits for a patient.”

Elsayed is the lead author in a first-of-its kind international study that includes a few cases handled originally by legendary mesothelioma specialist Dr. David Sugarbaker.

In the report, authors detailed the factors that could justify a questionable, second mesothelioma surgery for this rare and incurable disease – and the tangible results.

Oxford University Press published the study on behalf of the European Association for Cardio-Thoracic Surgery in January.

“There are cancer centers – some very good ones, too – that even debate the wisdom of a first radical surgery for mesothelioma. There is no real consensus,” Elsayed said. “But we found factors, that if present, can lead to better chances of benefiting from a second operation.”

All patients in the study had either a pleurectomy and decortication or an extrapleural pneumonectomy surgery initially.

Mesothelioma Patient Selection Critically Important

The authors identified three key factors that improve chances of second-surgery success:

• A longer-than-normal, disease-free interval after the first procedure
• Epithelial cell type of mesothelioma, not sarcomatoid or biphasic cell types
• Localized recurrence rather than diffused recurrence.

“If the recurrence is diffused, you’re usually not going to improve quality of life with a second surgery, but only cause more pain,” Elsayed said. “The survival benefit won’t be there, so it’s probably not the right thing to do.”

Patients who are healthier overall, and typically younger, naturally have a much better chance of benefiting.

Elsayed said one reason for the study initially was the fact that his University Hospital in Cairo is among the leaders in mesothelioma treatment in the Middle East. It also is close to where a number of manufacturing plants used asbestos, a primary cause of mesothelioma cancer. The hospital, though, has handled only a handful of second surgeries.

Within the U.S. there are several specialty centers today doing the most aggressive surgeries, but only a few offering the option of a second radical surgery after recurrence.

Fewer than a third of patients diagnosed initially with pleural mesothelioma even qualify for a first aggressive surgery, and only a fraction of those return for a second surgery after recurrence.

“This study should elicit a call of hands for centers to share their experiences, to say either do it, or not do it,” Elsayed said. “Right now, you just don’t find a good number of centers doing that second operation.”

Earlier Mesothelioma Surgery Studies 

This most recent report focused on three smaller studies totaling 40 patients involved in a second major surgery with a curative intent for mesothelioma.

In the first group of 16 patients, there was a median survival of 20.4 months after the second surgery for those with epithelial cell type, but only 7.4 months survival for those with biphasic subtype.

For the epithelial group whose recurrence didn’t occur until 24 months or longer, the median survival was 35.8 months, compared to those with a recurrence within 12 months whose median survival was only 8.9 months.

In the second group of 16 undergoing a second surgery, two patients died before leaving the hospital. The other 14 had a median survival of 16 months. This was compared to a nine-month survival for patients receiving only follow-up chemotherapy without a second surgery, and only two months for those receiving no therapy after recurrence.

The third group of only eight patients had a median survival of 14.5 months after the second major surgery.

“There is no real solid evidence regarding a second surgery, but I think you could say it’s not out of the question for mesothelioma,” Elsayed said. “I think for patients, if your doctor sees the favorable factors, then you might see significant benefit.”

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