Surgery and Mesothelioma: Why Operate?

“And if thine eye offend thee, pluck it out.”

Matthew 18:9

Review and discussion of “Macroscopic complete resection: The goal of primary surgery in multimodality therapy for pleural mesothelioma,” by David J. Sugarbaker, Journal of Thoracic Oncology, 2006

Few medical treatments make as much intuitive sense as surgery. When something inside is broken or diseased or useless, the right surgery can often repair it or remove it. Cancers can be especially susceptible to surgical cures, particularly when combined with chemotherapy and radiation.

Malignant pleural mesothelioma, however, defies any such quick fix. Unlike solid tumors, most cases of mesothelioma grow as a sheet or layer, so they are rarely confined along easily reached contours. This makes the surgeon’s job much tougher than simply going in and cutting out a cancerous lump.

Meso tumors, since they grow as diffuse sheets of cancer, can be enormous. Seven to ten-pound tumors are common, and they can be so thick, widespread, and hardened into an impenetrable rind that they are virtually inoperable. Mesothelioma tumors can penetrate the chest wall and spread so that no degree of surgical skill can cut them out, or they can attach to sensitive organs like the aorta, making removal impossible.

The meaning of success

Despite these barriers, skilled surgeons who specialize in the treatment of mesothelioma can often perform successful surgery. Yet the success of such surgery is very different from a successful operation to repair a broken bone or replace a heart valve.

First, no available treatment can cure mesothelioma.[1] Treatment can, however, “improve the quality and duration of life.”[2] For a patient who is faced with living only 4-12 months after diagnosis if nothing is done,[3] the prospect of surgery that can extend life up to five years[4] is often an easy decision.

However, it’s important to understand that even though in the long term the surgeon defines successful surgery as surgery that extends the patient’s life, when he’s in the operating theatre the actual surgery is evaluated very differently. The goal of surgery, when combined with radiation and chemotherapy, is what surgeons call “macroscopic complete resection.”[5] In plain English, the successful surgery is one that removes all of the tumor that the surgeon can see—all visible tumor.

The reason for this is that debulking, or making the tumor smaller by cutting it out, correlates with longer survival times when combined with chemo and radiation. Since cancer cells are microscopic, and since the meso tumor is a diffuse, uneven sheet, even the most precise surgeon can never visually cut away all of the cancer. This means that for meso surgeons, even a “successful” surgery that removes all visible tumor will leave behind cancer cells.

The remaining invisible cells eventually grow back and cause the disease to recur. Although chemotherapy and radiation can help reduce the cancer even further following surgery, virtually every case of pleural mesothelioma results in an eventual regrowth of the tumor. However, for the right patients, a macroscopic complete resection followed by chemo and radiation can result in meaningful extension of life.[6]

Maximal debulking v. smart debulking

In order to get rid of as much tumor as possible, surgeons use one of two techniques: pleurectomy with decortication (PD) and extrapleural pneumonectomy (EPP). With PD, the tumor is scraped, cut, and lifted off the lung and surrounding organs. With the EPP, the lung, diaphragm, and heart sac are amputated along with the attached tumor.

Since the EPP completely removes the lung and a significant amount of surrounding healthy tissue, surgeons have favored it as the procedure that removes the most tumor. However, since the surgery is so aggressive and invasive, post-operative death and the extraordinary complications that result require intensive management and care.[7] Quality of life for EPP patients has never been measured in a clinical study, but anecdotal evidence suggests that pain, complications, and greatly reduced mobility are often severe.

The PD leaves the lung intact. Fewer patients die during or immediately after surgery. There are fewer complications, and quality of life may be higher since patients actually keep their lung. Subsequent illnesses such as cold or pneumonia are more easily beaten back. Most importantly, the best EPP surgeons recognize that meticulous pleurectomy performed on the appropriate patient can result in the “holy grail”: complete macroscopic resection.[8]

In Europe, surgeons have begun shifting to the PD as they get complete macroscopic resections without the postoperative death, severe complications, and quality of life issues associated with EPP. In the eastern U.S., surgeons such as Harvey Pass regularly perform the PD. On the West Coast, Dr. Robert Cameron in Los Angeles is the only surgeon who has been regularly performing PD for the last fifteen years. [link to PHLBI web site]