Latest Study Compares Major Pleural Mesothelioma Surgeries

Mesothelioma patients may benefit more from aggressive extrapleural pneumonectomy surgery than from the lung-sparing pleurectomy and decortication currently being recommended as an alternative by many specialists today.

According to the most recent study from Italy, extrapleural pneumonectomy, or EPP, allowed mesothelioma patients diagnosed with high symptom burden to live a longer, better-quality life than with the more popular pleurectomy and decortication surgery, also known as P/D.

Journal of Clinical Medicine published the latest report on Oct. 29, authored by thoracic oncology specialists at Tor Vergata University Policlinico in Rome.

“Extrapleural pneumonectomy demonstrated the most durable effects,” the study authors wrote. “Pleurectomy/decortication achieved some temporary advantages in symptom control, especially in the first months after surgery, but we noticed a more effective, long-lasting pain control after extrapleural pneumonectomy.”

Quality of Life Better With EPP

The study results, which are contrary to earlier reports and a growing trend, were based on 55 pleural mesothelioma patients in Rome who underwent one of the two major surgeries over a 14-year period. They were part of a multidisciplinary treatment plan.

Twenty-nine patients had EPP surgery, and 26 had the P/D surgery. Those with the EPP fared better overall.

Comparison of quality-of-life determinants and symptoms were done before mesothelioma surgery, then again at three months, six months, 12 months and 24 months after surgery.

Measurements included a six-minute walk, body pain, physical functioning, vitality and mental health.

“Improvement in physical, social and pain-related measured parameters lasted for a longer time span in the extrapleural pneumonectomy group,” authors wrote. “Both procedures revealed a three-month improvement in many symptoms and the quality of life.”

No differences between the two surgeries were found in the chemotherapy  and radiotherapy compliance rate that was part of the overall treatment plan.

Median overall survival was 20 months for those having EPP and 13 months for those receiving P/D surgery. At the two-year mark, five of the 26 P/D patients were alive, compared to nine of the 29 EPP patients. At three years, only four EPP patients were still living.

“Given life expectancy is generally low, the quality of life assumes a leading role,” authors wrote. “These results confirm the efficacy of extrapleural pneumonectomy in local control of disease.”

More Precise P/D Less Risky

Study results were in contrast to the growing belief among thoracic oncologists today that the EPP surgery should rarely be used because it is aggressive and has the potential for debilitating side effects.

Mesothelioma, a rare cancer caused by a long-before exposure to asbestos fibers, typically starts in the thin lining around the lungs and metastasizes throughout the thoracic cavity.

The P/D surgery, which is more detailed and precise but less life-altering than the EPP, removes the lining around the lung and all visible tumor cells throughout the thoracic cavity. Surgery can last as long as 10 hours.

EPP surgery can provide a more complete tumor resection. It involves removing the pleural lining, the whole diseased lung and major parts of the diaphragm and pericardium.

Less than a third of pleural mesothelioma patients are even considered for either surgery because most are not diagnosed until the disease is too far advanced.

Most other studies have shown little difference in median survival times between the two procedures – ranging from 15 to 24 months – but most have concluded there is a greater deterioration in quality of life with the more aggressive EPP.

Dr. David Sugarbaker Pioneered EPP

The EPP surgery, which was pioneered by legendary thoracic surgeon Dr. David Sugarbaker almost 20 years ago, is not used as often as it once was. Many surgeons believe the risks of such a major surgery outweigh the benefits, making it less attractive.

There have been wonderful success stories, though, despite its decline in use. One of Sugarbaker’s greatest achievements with the EPP is Tim Crisler of Kennesaw, Georgia, believed to be America’s longest living pleural mesothelioma survivor.

Crisler, 66, recently celebrated his 20th year of post-surgery survival.

Sugarbaker died in 2018, leaving Crisler and his EPP surgery as part of his legacy.

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