Feasibility and safety of extended pleurectomy/decortication for malignant pleural mesothelioma. A single group experience

Abstract

Surgery is part of a multimodal therapeutic approach to malignant pleural mesothelioma (MPM) although its real beneficial effect is still controversial. The optimal precise sequence of treatments within the trimodality is unclear, and should be decided upon a multidisciplinary consensus for each individual patient. Here, we analyzed the perioperative data of 19 MPM patients who underwent extended pleurectomy/ decortication (EPD) with curative intent. The mean age at diagnosis was 67 years; 11 males and eight females. Ten patients were diagnosed with MPM via medical thoracoscopy (MT), and nine via video-assisted thoracoscopic surgery (VATS). The vast majority of cases harbored epitheliod forms. We compared neoadjuvant chemotherapy (NCT) followed by surgery (11 cases) versus surgery followed by adjuvant chemotherapy (ACT, 8 cases) within a 3-year period. All patients had extended pleurectomy/ decortication and none had an extended pneumonectomy. Analysis of survival curves suggested that the short-term outcomes are better with upfront EDP followed by ACT if compared to EDP preceded by NCT. Although limited, the data highlighted the safety and feasibility of EPD, with manageable postoperative complications and no major burden for the patients.

Anaesthetic and perioperative considerations for extrapleural pneumonectomy and extended pleurectomy/decortication: a scoping review protocol

“…A recent small study by an Italian single-centre thoracic unit highlighted the role of ePD in improving short-term survival outcomes if performed prior to the administration of systematic chemotherapy compared with post-chemotherapeutic treatment. 29 To date, there is considerable bias in the literature pertaining to outcome measures post-EPP and post-ePD dependent on institutional experience and limited sample size reporting. 29 Thus, the decision to perform EPP or ePD, and the role of surgery in the multimodality treatment of PM, should be made on a case-by-case basis by a multidisciplinary team of specialists, including thoracic surgeons, medical oncologists, radiation oncologists, pulmonologists and anaesthetists in consultation with the patient and their family.…”

“… 29 Thus, the decision to perform EPP or ePD, and the role of surgery in the multimodality treatment of PM, should be made on a case-by-case basis by a multidisciplinary team of specialists, including thoracic surgeons, medical oncologists, radiation oncologists, pulmonologists and anaesthetists in consultation with the patient and their family. 29–31 …”

“…29 To date, there is considerable bias in the literature pertaining to outcome measures post-EPP and post-ePD dependent on institutional experience and limited sample size reporting. 29 Thus, the decision to perform EPP or ePD, and the role of surgery in the multimodality treatment of PM, should be made on a case-by-case basis by a multidisciplinary team of specialists, including thoracic surgeons, medical oncologists, radiation oncologists, pulmonologists and anaesthetists in consultation with the patient and their family. [29][30][31] Surgery for EPP/ePD is a morbid and prolonged procedure involving the mediastinum, resulting in significant perturbations in cardiopulmonary haemostasis, 4 and other complications such as supraventricular arrhythmia, 15 32-37 cardiac failure, 32 36 thromboembolism, 32 35 respiratory failure, 32 36 renal failure, 32 pneumonia, 33 34 36 empyema and bronchopleural fistula.…”

“…29 Thus, the decision to perform EPP or ePD, and the role of surgery in the multimodality treatment of PM, should be made on a case-by-case basis by a multidisciplinary team of specialists, including thoracic surgeons, medical oncologists, radiation oncologists, pulmonologists and anaesthetists in consultation with the patient and their family. [29][30][31] Surgery for EPP/ePD is a morbid and prolonged procedure involving the mediastinum, resulting in significant perturbations in cardiopulmonary haemostasis, 4 and other complications such as supraventricular arrhythmia, 15 32-37 cardiac failure, 32 36 thromboembolism, 32 35 respiratory failure, 32 36 renal failure, 32 pneumonia, 33 34 36 empyema and bronchopleural fistula. 32 36 37 Consequently, a 2018 systematic review found perioperative mortality from EPP to be as high as 11.8%, with complications occurring in 82.6% of patients 2 -a reflection of the many challenges that may arise throughout the perioperative period.…”

Pleural Mesothelioma: Treatable Traits of a Heterogeneous Disease

“…In this context, the sequential combination between surgery and chemotherapy also deserves better investigation. Preliminary results for a case series of our group have shown better short-term outcomes with upfront extended pleurectomy/decortication (EDP), followed by adjuvant chemotherapy (CT) if compared to EDP preceded by neoadjuvant CT [80].…”