A study looking at many patients with pleural mesothelioma found that there is not enough of a survival advantage to support the use of extrapleural pneumonectomy surgery (EPP). The study was done at the MD Anderson Cancer Center at the University of Texas. EPP is the most aggressive surgery for mesothelioma and at one point was the most popular surgery, but pleurectomy and decortication (P/D) is now the surgery of choice. When the two surgeries were compared in the study, there was a higher death rate for the extrapleural pneumonectomy patients.
In recent years, when patients have had the option to do the most aggressive mesothelioma surgery, they instead chose to do a pleurectomy and decortication procedure. Looking at MD Anderson patients as an example, from 2000 to 2006 122 patients underwent extrapleural pneumonectomy surgery while from 2014 to 2019, only 19 underwent the same procedure. On the reverse side, 48 pleurectomy decortication surgeries were performed during the 2014 to 2019 time period. Extrapleural pneumonectomy surgery removes the entire lung, the lining, and parts of the diaphragm and pericardium lining, while pleurectomy and decortication surgery removes all visible tumors on the lung and other tumors in the thoracic cavity.
The study had 282 patients who either had EPP (66 percent) or P/D surgery (34 percent) from the years 2000 to 2019. The study also found that epithelioid histology, macroscopic complete resection, adjuvant radiation therapy, and surgeries done in more recent years had better survival. There were 21 perioperative deaths: seven from cardiac arrest, six from respiratory failure, and five from infection. Other studies have had varied results with perioperative EPP death rates. Twenty years ago, Dr. David Sugarbaker, the pioneer that created EPP surgery, had a three to five percent mortality rate in his study while others have had up to 18 percent.
Some cancer centers still like using EPP surgery in certain cases even though its overall use has declined. The Princess Margaret Cancer Center in Toronto does EPP surgeries, but modifies them by using tumor priming, high dose radiation before the surgery is performed. The center found the three-year survival rate for this treatment to be 58 percent for regular mesothelioma patients and 84 percent for epithelioid mesothelioma patients. Princess Margaret’s approach to surgery is different than most cancer centers. Typically, doctors use chemotherapy before surgery and radiation after (if used at all).
The study concludes that P/D surgery should be the main surgery type used if patients are able to undergo surgery.