Radical Surgery for Mesothelioma: How CanWe Obtain Evidence?

Abstract

Asbestos exposure in industry and construction sites in the 1960s and 1970s has left a legacy of mesothelioma, a diffuse pleural cancer, with a lag time of 40 to 50 years and due to peak around 2015 to 2020. Some surgeons believe that by radical surgery they can prolong life and relieve symptoms, but the evidence comes from very carefully selected series. How do surgeons respond to demand for evidence of benefit? In this article we explore how evidence for major surgical operations has been gained and how mesothelioma fits into this history.

A phase II study of intrapleural immuno-chemotherapy, pleurectomy/decortication, radiotherapy, systemic chemotherapy and long-term sub-cutaneous IL-2 in stage II–III malignant pleural mesothelioma☆

“…So for stage II and III disease, we preferred to perform a pleurectomy/decortication which, even less radical than EPP [9], results in lower morbidity and allows most patients to tolerate a complex multimodality treatment. It is extremely suggestive and important that, recently, Australian authors [18] showed, in an animal model, that the persistence of tumoural antigens after incomplete debulking, in combination with chemotherapy and immunotherapy, is critical for the induction of long-term immunity.…”

“…P/D is a lower risk operation because the lung is left in place but does not allow removal of all gross tumor in patients with locally advanced disease and is associated with a high rate of local relapse [9,10]. Adjuvant hemithoracic radiotherapy is notoriously difficult to administer after P/D because of the risk of radiation pneumonitis after even low radiation doses.…”

“…Surgery, both pleurectomy/decortication (PD) and extrapleural pneumonectomy (EPP) according to the policy of the surgeon, has been adopted in most of the multimodality protocols as a cytoreductive treatment [8,9]. There is no evidence of the superiority of EPP versus PD, but we must wait for the end of the ongoing MARS trial in the UK [10].…”

Radical surgery for mesothelioma

“…w6-w9 Radical surgery has been performed infrequently in the United Kingdom, with an average of only 20 patients per year in the past five years. Some patients and their doctors desperately seek radical surgery as their only hope, but others have doubts about the evidence 11. A trial is needed, and a pilot feasibility study (the mesothelioma and radical surgery “MARS” trial, funded by Cancer Research UK) is now under way.…”

“…Then with the diagnosis made the disease can be staged. If the pathological stage is early extrapleural pneumonectomy should be considered, and we would recommend that this is done in the context of multimodality treatment and within a study 11. If the tumour is inoperable management can be with chemotherapy, and again it would be preferable that this is within a study 12…”