The effects of an intentional transition from extrapleural pneumonectomy to extended pleurectomy/decortication

Sharkey, Annabel J.; Tenconi, Sara; Nakas, Apostolos; Waller, David

doi:10.1093/ejcts/ezv403

Cited by 45 publications

(40 citation statements)

References 18 publications

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“…can be applied to a wider cohort of patients due to its lower detrimental effect and mortality rate, without affecting long term results [49].…”

Section: Which Approach For Radical Surgery?mentioning

confidence: 99%

“…More recently, Lang-Lazdunski [48] published the results of a multimodality approach using EPD for MPM; one hundred and two patients had a median survival of 32 months and a 2-year survival of 62.9%; when observing restricted groups of patient N0 or with epithelioid histology 2-year survival was 66.7% and 76,5%respectively. Concurrently, in a report comparing EPP and EPD performed in a single institution, Sharkey[49] reported outcomes of 358 patients; the EPD population had a median survival of 12.3 months, while for patients treated with EPP it was 12.9 months; when calculated for patients with epithelioid, node-negative disease, survival was significantly higher accounting for 24.2 months and 20.7 months respectively.Furthermore, an increasing interest in biomarkers as prognostic factors is developing. White blood cells count, LDH, PCR levels, NLR (Neutrophil/Lymphocytes ratio), PLR (Platelet/Lymphocytes Ratio), albumin levels and hemoglobin levels have been related to prognosis, but their clinical application is still unestablished[50,51].…”

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confidence: 99%

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The role of thoracic surgery in the management of mesothelioma: an expert opinion on the limited evidence

Bertoglio

Waller

2016

Expert Review of Respiratory Medicine

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Surgery has a key role at different points in the management of Malignant Pleural Mesothelioma. Diagnosis with video assisted thoracoscopy offers excellent sensitivity and specificity and a direct view of the pleural cavity to verify the extent of the tumor. Nodal involvement can be assessed by mediastinoscopy and either talc pleurodesis or partial pleurectomy can be used for symptom control in advanced stage disease. Extra Pleural Pneumonectomy (EPP) and Extended Pleurectomy Decortication (EPD) are used to prolong survival although the benefit of radical surgery has not has been fully clarified; EPP failed to show its benefit in the MARS trial and EPD is currently under investigation in the MARS2 trial. More randomized prospective trial data are needed to fully understand the role of radical surgery in the treatment of pleural mesothelioma.

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“…can be applied to a wider cohort of patients due to its lower detrimental effect and mortality rate, without affecting long term results [49].…”

Section: Which Approach For Radical Surgery?mentioning

confidence: 99%

mentioning

confidence: 99%

The role of thoracic surgery in the management of mesothelioma: an expert opinion on the limited evidence

Bertoglio

Waller

2016

Expert Review of Respiratory Medicine

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“…[1][2][3][4] However, lung-sparing pleurectomy-decortication (P/D) is increasingly a preferred surgical approach for MPM. 5,6 Safe delivery of cytotoxic radiation to the hemithorax with two intact radiosensitive lungs is challenging. Conventional matched photonelectron radiation techniques are insufficiently able to spare the underlying ipsilateral lung, so the techniques result in excess toxicity.…”

Section: Introductionmentioning

confidence: 99%

Phase II Study of Hemithoracic Intensity-Modulated Pleural Radiation Therapy (IMPRINT) As Part of Lung-Sparing Multimodality Therapy in Patients With Malignant Pleural Mesothelioma

Rimner

Zauderer

Gomez

et al. 2016

JCO

158

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We conducted a two-center phase II study to determine the safety of hemithoracic intensitymodulated pleural radiation therapy (IMPRINT) after chemotherapy and pleurectomy-decortication (P/D) as part of a multimodality lung-sparing treatment. Patients and MethodsPatients received up to four cycles of pemetrexed plus platinum. If feasible, P/D was performed. Hemithoracic IMPRINT was administered to a planned dose of 50.4 Gy in 28 fractions. The primary end point was the incidence of grade 3 or greater radiation pneumonitis (RP). ResultsA total of 45 patients were enrolled; 18 were not evaluable (because of disease progression before radiation therapy [RT], n = 9; refusal of surgery or RT, n = 5; extrapleural pneumonectomy at time of surgery, n = 2; or chemotherapy complications, n = 2). A total of 26 patients received pemetrexed plus cisplatin, 18 received pemetrexed plus carboplatin, and four received a combination. Thirteen patients (28.9%) had a partial response, 15 patients (33.3%) experienced disease progression, one patient died during chemotherapy, and all others had stable disease. Eight patients underwent P/D or an extended P/D, and 13 underwent a partial P/D. A total of 27 patients started IMPRINT (median dose, 46.8 Gy; range, 28.8 to 50.4 Gy) and were evaluable for the primary end point (median followup, 21.6 months). Six patients experienced grade 2 RP, and two patients experienced grade 3 RP; all recovered after corticosteroid initiation. No grade 4 or 5 radiation-related toxicities were observed. The median progression-free survival and overall survival (OS) were 12.4 and 23.7 months, respectively; the 2-year OS was 59% in patients with resectable tumors and was 25% in patients with unresectable tumors. ConclusionsHemithoracic IMPRINT for malignant pleural mesothelioma (MPM) is safe and has an acceptable rate of RP. Its incorporation with chemotherapy and P/D forms a new lung-sparing treatment paradigm for patients with locally advanced MPM.

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“…Initially P/D was considered only palliative, but during the decades its role was redefined and this type of surgery gained an important position as a radical surgery. Recent studies have shown that survival time after EPP and P/D is similar, while mortality and morbidity are higher post EPP (24,40,41).…”

Section: Discussionmentioning

confidence: 99%

“…Preservation of the underlying lung seems to guarantee a lower mortality and morbidity rate: Cao et al reported a perioperative mortality of 2.9% (vs. 6.8% of EPP) and morbidity of 27.9% (vs. 62% of EPP) (15), Flores showed a mortality and morbidity rate of 4% (vs. 7% of EPP) and 6.4% (vs. 10% of EPP) respectively (22). Several authors also insisted on the importance of a case-by-case patient's characteristics evaluation: the EPP and P/D should not be considered as alternative approaches (22,23) and P/D could be used in a greater number of patients because of its lower mortality and morbidity rate, with similar long-term survival rate (24).…”

Section: Discussionmentioning

confidence: 99%

Surgery for malignant pleural mesothelioma: an international guidelines review

Ricciardi¹,

Cardillo²,

Zirafa³

et al. 2018

J. Thorac. Dis.

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Currently there is no universally accepted surgical therapy for malignant pleural mesothelioma (MPM). The goal of surgery in this dismal disease is a macroscopic complete resection (MCR) and there are two types of intervention with a curative intent. At one side, there is the extrapleural pneumonectomy (EPP) which consists in an en-bloc resection of the lung, pleura, pericardium and diaphragm and at the other side, there is pleurectomy/decortication (P/D) a lung-sparing surgery. Initially, EPP was considered the only surgical option with a curative aim, but during the decades P/D have acquired a role of increasing importance in MPM therapy. Several randomized prospective trials are required to establish the best strategy in the treatment of pleural mesothelioma. Although which is the best surgical option remains unclear, the International Mesothelioma Interest Group (IMIG), recently have stated that the type of surgery depends on clinical factors and on individual surgical judgment and expertise. Moreover, according to the current evidence, the surgery should be performed in high-volume centres within multimodality protocols. The aim of this study is to examine the currently available international guidelines in the surgical diagnosis and treatment of MPM.

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The effects of an intentional transition from extrapleural pneumonectomy to extended pleurectomy/decortication

Abstract: The transition from EPP to EPD in our standard practice has enabled us to operate on more elderly, frail patients with no significant increase in use of hospital resources, and without detriment to overall survival.

Cited by 45 publications

References 18 publications

The role of thoracic surgery in the management of mesothelioma: an expert opinion on the limited evidence

The role of thoracic surgery in the management of mesothelioma: an expert opinion on the limited evidence

Phase II Study of Hemithoracic Intensity-Modulated Pleural Radiation Therapy (IMPRINT) As Part of Lung-Sparing Multimodality Therapy in Patients With Malignant Pleural Mesothelioma

Surgery for malignant pleural mesothelioma: an international guidelines review

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