Video-assisted Pleurectomy/Decortication to Treat Mesothelioma in Elderly Patients

"All men are rebels."

Fyodor Dostoevsky, The Brothers Karamazov

Review and discussion of "The role of video assisted thoracoscopic pleurectomy/decortication in the therapeutic management of malignant pleural mesothelioma" by Apostolos Nakas et al., European Journal of Cardio-Thoracic Surgery, 2008

A few years ago, mesothelioma patients who elected to treat their cancer with surgery were almost invariably steered towards the extrapleural pneumonectomy, or EPP. No randomized trials comparing surgery with an alternative treatment or comparing EPP to other procedures such as pleurectomy/decortication (PD) have ever been done.[1]

But a small rebellion may be taking place.

Today, as surgeons learn more about the comparative benefits between PD and EPP, they have reviewed prior surgeries and concluded that PD, video-assisted PD, and EPP all may result in extended life and control of symptoms when used with the right patient in conjunction with chemotherapy and radiation.[2]

Rather than a one-surgery-fits-all approach, centers experienced with mesothelioma have begun to aggressively explore the notion of matching particular procedures depending upon disease stages, age, physical condition, and other parameters. One such group is patients over age 65.

Pluses and a lot of minuses

The downside for the most common surgery, the EPP, has always been the staggeringly high number of patients who die during or immediately after surgery. In 1976, one of the first published reports showed that 31% of all patients died during or immediately after surgery.[3] Those numbers have over timed dropped on average to 4-7%[4], but many surgeons-not to mention patients-still consider the operation an unacceptably high risk.

Among patients diagnosed over the age of 65, the risk of death from surgery skyrockets back to 23%.[5] Hospital stays after an EPP are also lengthy, up to 36 days on average in the VATS study by Nakas et al. Of the study's patients who received the EPP, only one did not suffer non-fatal major complications. Clearly, the decision to undergo EPP is a major one.

Although PD is less radical than EPP and often demonstrates an equal or superior survival time with better quality of life, many older patients in physically poor condition cannot tolerate the open chest surgery required by the procedure. Mortality in the Nakas study for those aged over 65 was 12.5%.

The PD can also be accompanied by painful conditions such as persistent air leak in older, weaker patients.

A solution for older patients?

EPP is a very unfriendly procedure for older patients. Studies have confirmed that the older the patient, the worse the outcome.[6] There is, however, a viable solution for many older patients: video-assisted PD. This surgery removes the tumor by making small incisions and guiding the "debulking" process via video camera.

It is much less invasive than either EPP or PD, and results in much less stress on the system while allowing reduction of the tumor [see "Surgery and Mesothelioma: Why Operate?" for a discussion of tumor reduction and its importance in surgery]. The disadvantage is that unlike the standard PD which allows full access to the chest and the possibility of complete macroscopic resection, the video guided procedure removes less of the tumor.

In addition to shortened hospital stays (14.3 days), lowest mortality (7.1%), and the longest average survival (14 months), patients who received the video assisted surgery experienced significant improvement from pain (58%) and alleviation of shortness of breath (83%). This last item is certainly caused by the procedure's aim of removing enough tumor so that the lung can reinflate.

For those patients who are not candidates for EPP or standard PD surgery, the video assisted pleurectomy/decortication can provide some increase in survival time, alleviation of painful symptoms, and avoid the complications commonly found in a more drastic approach.

*** POSTED OCTOBER 8, 2008 ***