Pleural Mesothelioma Surgery

Pleural mesothelioma is a rare but aggressive cancer that predominantly affects the lining of the lungs, known as the pleura. The nature of the disease often leads to late-stage diagnosis, limiting treatment options. One of the cornerstone treatments for managing this formidable disease is surgical intervention. Surgery primarily aims at extending life and relieving symptoms.

Types of Surgical Interventions

Extrapleural Pneumonectomy (EPP)

Extrapleural Pneumonectomy, or EPP, is an extensive surgical procedure. It involves the removal of the affected lung, a portion of the diaphragm, and the pleura. EPP is usually recommended for patients in the early stages of mesothelioma without lymph node involvement. A landmark study by Sugarbaker et al. found that patients undergoing EPP, when complemented by chemotherapy and radiation, had a median survival rate of 19 months. This was considerably higher than those who did not undergo any surgical intervention.

Pleurectomy/Decortication (P/D)

Pleurectomy/Decortication (P/D) is a less radical surgical approach that focuses on the removal of only the pleura and any restricting tumor mass from the lung. The MARS-2 trial indicated that P/D, when paired with chemotherapy, could offer survival benefits comparable to EPP but with fewer surgical complications.

Palliative Procedures

In some cases, especially in advanced stages or for patients who are not suitable candidates for radical surgeries, palliative procedures may be recommended. Pleurodesis and indwelling pleural catheters are examples of such interventions. These procedures aim to manage symptoms like pleural effusions and can significantly improve the quality of life, as observed in a study by Vogelzang et al.

Risks, Complications and Adjuvant Therapies

Surgery for mesothelioma comes with its set of risks. Patients may face complications such as respiratory distress, infections, and bleeding. Due to the invasive nature of these surgical options, patients may require extended hospital stays and are at risk of additional postoperative complications, such as arrhythmias or pneumonia.

Surgery alone is generally not sufficient for treating mesothelioma. Therefore, adjuvant therapies like chemotherapy and radiation are typically administered to improve treatment outcomes. The MARS trial demonstrated that a multimodal approach that included surgery and adjuvant therapies could increase median survival rates significantly.

As we move forward, advancements in surgical techniques, minimally invasive procedures, and robotic surgery offer hope for better outcomes. Ongoing trials are exploring the potential roles of immunotherapy and targeted therapies as adjuvant treatments, which could further improve surgical outcomes and prolong survival.

Conclusion

Surgery continues to play a critical role in the management of pleural mesothelioma. While risks and challenges exist, well-planned and executed surgical interventions have shown promise in extending survival and improving the quality of life for patients with this aggressive disease.

Bibliography

- Sugarbaker, D. J., Flores, R. M., Jaklitsch, M. T., et al. (1996). "Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: Results in 183 patients." *Journal of Thoracic and Cardiovascular Surgery*, 117(1), 54--65.

- MARS-2 trial (2019). "Pleurectomy/decortication (Extended Pleurectomy) Versus no Pleurectomy Decortication in the Surgical Management of Malignant Pleura Mesothelioma." *ClinicalTrials.gov Identifier: NCT02040272*.

- Vogelzang, N. J., Rusthoven, J. J., Symanowski, J., et al. (2003). "Phase III Study of Pemetrexed in Combination With Cisplatin Versus Cisplatin Alone in Patients With Malignant Pleural Mesothelioma." *Journal of Clinical Oncology*, 21(14), 2636--2644.

- MARS trial (2011). "Surgery in Treating Patients With Malignant Pleural Mesothelioma: Results From the Mesothelioma and Radical Surgery (MARS) Randomized Feasibility Study." *The Lancet Oncology*, 12(8), 763-772.

- Flores, R. M., Pass, H. I., Seshan, V. E., et al. (2008). "Extrapleural Pneumonectomy Versus Pleurectomy/Decortication in the Surgical Management of Malignant Pleural Mesothelioma: Results in 663 Patients." *Journal of Thoracic and Cardiovascular Surgery*, 135(3), 620--626.