Radical Pleurectomy/Decortication Saves Patients Bypassed by EPP

“In those days, everybody got the T.B., they died.”

Huddie Ledbetter, T.B. Blues

Review and discussion of “Open lung-sparing surgery for malignant pleural mesothelioma: the benefits of a radical approach within multimodal therapy” by Apostolos Nakas et. al., European Journal of Cardio-thoracic Surgery, 2008

When doctors first began treating malignant pleural mesothelioma with surgery, the extrapleural pneumonectomy (EPP) was considered the best option for extending life. Doctors are no longer sure that is the case. One of the most recent articles reviewing 633 surgeries concluded that when other factors are taken into account, EPP’s superiority over pleurectomy/decortication (PD) is unclear.[1] This study reported that PD patients’ average survival time was 16 months, versus 12 months for EPP.[2]

The better survival times reported for EPP patients when all factors are taken into account may be a result of strong selection biases that resulted in choosing healthier patients, and the fact that more EPP patients may have received subsequent chemotherapy and/or radiation treatment.[3] Combining chemo and radiation with surgery has long been the foundation of multimodal therapy, and with other variables could easily explain the “better” results of the EPP. The difficulty in assessing the effect of surgery on mesothelioma is echoed by other researchers as well.[4]

One of the reasons that the value of surgery hasn’t been conclusively ruled on is that there has never been a randomized clinical trial comparing patients with surgery to patients without. Such a trial is underway in the United Kingdom, but results are still a ways off.

Not all carpentry work requires a hammer

Despite the fuzziness in general about whether EPP is better than PD, surgeons are realizing that there are some situations in which PD has conclusively shown its worth as an excellent treatment modality. One such situation is when patients are ineligible for EPP. Since EPP has been found to have no meaningful impact on survival for patients whose cancer has spread to the mediastinal or carinal lymph nodes, some surgeons have ceased offering it for these patients.[5] 

Patients with clinical tumor staging T4 (the tumor has broken through the chest wall and invaded surrounding major organs), whose cancer has metastasized to distant locations, whose regional lymph nodes have become involved to the level of N2, who are over 70, whose lung functions are too weak, or who have serious problems with blood pressure are all excluded as candidates for EPP surgery.

The consequence is that for these patients surgeons sometimes choose to perform palliative PD surgery instead of the radical PD. In its palliative form, the PD is done merely to alleviate symptoms, not to extend life. Surgeons have often mistakenly thought that complete removal of all visible tumor cannot be done with the PD. The radical PD, however, when done properly, is performed with intent to remove all visible tumor by stripping out the cancer and by replacing those parts of the diaphragm and pericardium that have been affected. As Nakas et al. note, “We have always considered radical P/D a radical approach, since it was aiming to achieve complete macroscopic tumour clearance.”[6]

In other words, the PD can be used to eliminate all visible tumor and extend life just as effectively as the EPP. The study carried out by Dr. Nakas was designed to see if patients ineligible for the EPP who had been consigned to the palliative form of the PD could actually receive therapeutic benefits and longer life by using the radical PD instead.

More life, fewer hazards

Prior studies have shown that EPP has a much higher mortality rate than PD, with rates as high as 7%.[7] In the Nakas et al. study, Fifty-one patients ineligible for EPP were selected for radical PD and their outcomes were compared with fifty-one patients who had received the palliative PD. The results showed that the radical PD did in fact achieve a complete clearance of visible tumor in all but two of the fifty-one patients. More patients from the palliative PD group died within 90 days (15 patients) than did those from the radical PD group (5 patients). The study’s authors believe this may be related to the fact that a larger number of radical PD patients received chemo and/or radiation than patients in the palliative group.

Patients receiving the radical PD lived on average for 15.3 months after the surgery, whereas palliative PD patients lived on average 7.1 months. Most importantly, when comparing patients with epithelioid meso in the two groups rather than the biphasic or sarcomatoid types, the radical PD survival time shot up to 25.4 months versus 10.2 months for palliative PD patients.

These differences were so dramatic that the authors no longer offer palliative PD, choosing instead to offer those patients who seek palliative care only a video assisted pleurectomy rather than the open-chest palliative PD. Needless to say, since all patients were ineligible for EPP, the increased longevity and alleviation of symptoms offered by the radical PD was superior to EPP.

Conclusion

Rather than applying a one-EPP-fits-all-mesothelioma approach, doctors are increasingly understanding that PD offers a number of clear and measurable advantages even in cases where, at first blush, the patient has no hope at all. This study by Nakas et al. shows that patients ineligible for the EPP may still benefit from the radical PD, and that in any event purely palliative open-chest pleurectomy no longer has a place in the meso surgeon’s little black bag.

Additionally, this study advises patients to look beyond the generalizations of meso treatment and survival data. Very specific case parameters such as cell type, tumor stage, age, gender, performance status, and other factors mean that rather than nihilism and defeatism, radical PD can offer patients realistic hope for longer life and better management of their disease.

*** POSTED OCTOBER 8, 2008 ***