Pleural Surgical Management As Presented at the Mesothelioma Applied Research Foundation Third Annual International Symposium on Malignant Mesothelioma
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by Dr. Raja Flores, Dr. Harvey Pass on October 21, 2006.
Dr. Raja Flores is a thoracic surgeon from Memorial Sloan-Kettering Cancer Center in New York. Dr. Harvey Pass is Chief of Thoracic Surgery and Oncology at NYU School of Medicine and Comprehensive Cancer Center in New York and is Chairman of the Science Advisory Board of the Mesothelioma Applied Research Foundation (MARF). On October 21, Drs. Pass and Flores discussed the surgical treatments offered for pleural mesothelioma. What follows is a summary of their discussion. Approximately 3,000 new cases of mesothelioma occur each year. Most are epitheliod mesothelioma of which the majorities affected are men. Mesothelioma in essence freezes muscles in the diaphragm and lung resulting in a sort of frozen chest. The pleural lining fixes to the lung, trapping it. What occurs afterwards are diseases like pneumonia, infections, and sepsis (an infection caused by bacteria in the blood) which can ultimately be fatal. A proper diagnosis should be obtained before seeking treatment. A thoracentesis to remove any fluid build up in the lung is a telling diagnosis, but Dr. Flores suggests that a VATS (Video Assisted Thoracic Surgery) is the most accurate diagnosis. Once diagnosed, sarcomatoid mesothelioma patients tend to have poorer prognosis (opposed to epitheliod mesothelioma). Under a microscope, it is not always easy to differentiate between some of the mesothelioma types, but histological staining provides more accurate diagnosis. Dr. Flores suggests that it is important to monitor the cancer for approximately one week before performing surgery to ensure proper treatment is being given. Dr. Flores brings up the purpose of surgery, questioning whether it is getting rid of the tumor or getting rid of the diseased lung that can later cause a fatal infection. Understanding the purpose of a surgery is key to choosing a treatment plan. Regarding the historical treatment and outlook prognosis given to mesothelioma patients, Dr. Flores helps clear a few misconceptions. To begin with, Dr. Flores acknowledges that diagnosis and treatment options have improved significantly. Older data for mesothelioma patients is "contaminated" with patients improperly diagnosed with meso. Also, because a proper staging system is still being developed, all mesothelioma patients have been lumped in together. The reality is that all cancer patients should be considered at the appropriate stage of their disease so stage III patients were lumped in with stage I patients and there is "no wonder why everyone was told they had a poor prognosis." Because proper stage tracking was not occurring, all patients were given the same dismal outlook. With proper staging, patients have better tailored treatment options, including the type of surgery they can receive. Dr. Flores does not suggest that any patient merely opt for observation of the cancer. A talc pleurodesis (where a chemical agent is put into the lungs to prevent fluid accumulation) can be a good palliative treatment to ease breathing. Dr. Flores refers to another surgery known as palliative pleurectomy as a "bail out procedure." In his opinion the doctor cannot move the tumor and a lot of gross tumor is left inside, making the surgery an unnecessary burden on the patient with little benefit. More invasive surgeries include the Pleurectomy with Decortication (P/D) and an extra pleural pneumonectomy (EPP). In a P/D the surgeon debulks the tumor from the lung as best able but leaves the lung healthier and intact. A P/D is intended to cure a patient of mesothelioma and sparing the lung is a huge benefit. An EPP is also intended to cure the patient but is more radical because this surgery requires the lung to be removed. Much controversy exists between these two procedures. Dr. Flores believes that the EPP is theoretically more attractive because it keeps the entire tumor together in a pleural envelope and the tumor does not spread as easily to other areas. He also agrees that the EPP is an easier surgery to perform. Dr. Pass acknowledges though, that surgery should perform the greatest good for the patient, and says that he always keeps this in mind. Dr. Pass reiterates one of the significant problems of choosing between these surgeries-no statistical data exists between the long term benefits of an EPP verse a P/D. Doctors continue to get better at performing both types of surgery. Patients at a stage I tend to do much better with an EPP, with an average survival rate of approximately 30 months whereas patients at stage IV have an average survival of eight months. Recently, Dr. Pass has been performing more P/Ds than in the past. He first has to ensure that the patient can tolerate the surgery. He echoed the Pass Corollary, "You're only as good as what you do for the patient." Thus, Dr. Pass measures the disease progression before and after surgery and is always mindful of tailoring surgery to the patient. Both Dr. Pass and Dr. Flores agree that half of the battle occurs before a patient enters the operating room. A PET scan is recommended to detect exactly where the tumor is and to ensure that no disease exists outside of the chest. Only those patients with a contained tumor should elect surgery in the first place. Some criteria about surgical options entail placing the patient at the appropriate stage. For example, stage I patients have normal fluid, minimal bulk, and the lung still expands well. Sometimes, the doctor must reassess a treatment plan once inside if the disease stage is unclear before undergoing surgery. However the doctor is obligated to tell a patient that a P/D is not recommended even if the patient is stage I if the tumor is in bulk. For some patients, taking the whole lung is not advisable, but the doctor should be reasonable about when to take the lung or not. For patients at stage II, a P/D can be more difficult but a good surgeon has patience and knows what the endpoint should be. Heavy smokers should not have an EPP because they need both lungs. Those patients who have an EPP may not do better in the long run because they are surviving on only one lung. Taken holistically, patients who receive a P/D tend to do better than those who undergo an EPP. But both do well at an early stage, and females tend to recover from surgery better than men. The bottom line is that surgeons need to be flexible in their operations and therapies need to be improved as well. Educating "front line" doctors also needs to be addressed and is a huge concern for mesothelioma patients as many are misdiagnosed for several months. This education in medical offices is slowly happening due to news media and research. Unfortunately much of the burden falls on the patient to perform their own research and decide treatment options. Dr. Flores suggests patients continue to get a CT scan every six months, and Dr. Pass recommends every three months to monitor progression. *** NOVEMBER 1, 2006 *** |