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

Abstract

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.

Surgery for malignant pleural mesothelioma: an international guidelines review

“…Its incidence is related to asbestos exposure with a long latency period which can even be up to 40 years, the number of deaths from MPM in Europe is expected to have peak in 2020-2025 (1,2). The optimal treatment for mesothelioma remains under debate; thus a multimodal setting is generally used, but none of the available therapies, both alone or combined, are able to ensure good long-term survival (3).…”

“…Throughout the years different surgical approaches have been proposed (3), but a great debate around the role of surgery is currently ongoing. In case of resectable MPM (Table 1), during the last decade, the extrapleural pneumonectomy (EPP) was widely performed, but recently pleurectomy and decortication (P/D) and extended pleurectomy and decortication (EPD) have obtained an increasing number of consents (4).…”

The role of intracavitary therapies in the treatment of malignant pleural mesothelioma

“…Malignant pleural mesothelioma (MPM) is a rare disease with a frequently fatal prognosis, strictly related to asbestos exposure (1). To date, there is not a standard of care that might lead to satisfactory long-term outcomes; the association of cisplatin and pemetrexed as systemic therapy showed to give a survival advantage in a prospective randomized trial, while the MARS trial demonstrated a possible detrimental effect of ExtraPleural Pneumonectomy (EPP) after neoadjuvant chemotherapy compared with chemotherapy alone (2).…”

“…Nevertheless, results are still based on a large quantity of low-quality and retrospective evidences that make conclusions inconsistent. Consequently, to date, several different multimodality approaches combining surgery, chemotherapy and/or radiotherapy in different setting are commonly used in the treatment of MPM (1).…”

“…Recently, the use of lung sparing approaches (extended pleurectomy decortication, EPD; or pleurectomy decortication, P/D) is gaining more and more consensus (5) as it allows to considerably reduce postoperative complications and can extend the possibility of a surgical approach also for older people or those with a partially impaired lung function (1). Nevertheless, anatomical borders of the pleura prevent the possibility of a microscopically radical resection with diseasefree margins (R0), and Macroscopic Complete Resection (R1) is to date considered the target of a surgical resection (6).…”