Surgical Treatment of Pleural Mesothelioma

Now, let’s take a closer look at the role of surgery in treating pleural mesothelioma. Surgery is one of the main treatment options for this disease, but it’s important to understand that it’s not a standalone cure. Instead, surgery is often part of a broader treatment plan, which may include chemotherapy and radiation therapy—what we call ‘multimodal therapy.’

There are two primary surgical procedures used for pleural mesothelioma: Extrapleural Pneumonectomy (EPP) and Pleurectomy/Decortication (P/D). Each has its own goals, benefits, and risks, and the choice between them depends on factors like the stage of the disease, the patient’s overall health, and the surgeon’s expertise.

Extrapleural Pneumonectomy (EPP):
This is a more aggressive surgery. It involves removing the affected lung, the pleura (the lining around the lung), part of the diaphragm, and sometimes the pericardium (the lining around the heart). The goal is to remove as much of the cancer as possible in one ‘en bloc’ resection. While EPP can achieve a more complete removal of the tumor, it comes with higher risks, including complications and a longer recovery time. Studies have shown that median survival after EPP alone is less than one year, and in-hospital mortality rates can range from 0% to 20%.

Pleurectomy/Decortication (P/D):
This is a less aggressive option. It involves removing the pleura and any visible tumor while sparing the lung. P/D is often chosen for patients who may not tolerate the more extensive EPP. While it’s less invasive, P/D is associated with higher rates of local recurrence compared to EPP. However, it allows for better postoperative lung function and may be a better option for certain patients.

Both procedures aim to achieve what’s called ‘macroscopic complete resection,’ meaning the visible tumor is removed. However, because mesothelioma is a diffuse disease, microscopic cancer cells often remain, which is why additional treatments like chemotherapy or radiation are necessary.

It’s also worth noting that surgery for mesothelioma is not without controversy. Some experts question its overall impact on survival, especially when performed as a standalone treatment. For example, studies have shown that median survival after EPP or P/D alone is limited, which is why these surgeries are typically combined with other therapies.

Finally, it’s critical to have a thorough preoperative evaluation to determine if surgery is the right option. This includes imaging tests like CT, MRI, and PET scans, as well as invasive staging procedures like thoracoscopy or mediastinoscopy. These help ensure the cancer hasn’t spread too far for surgery to be effective.

In summary, surgery can play a key role in managing pleural mesothelioma, but it’s not a one-size-fits-all solution. The decision to proceed with surgery—and which type of surgery to choose—requires careful consideration of the patient’s unique situation and a team of experienced specialists.