Latest Study Compares Major Pleural Mesothelioma Surgeries

Research and clinical studies

Mesothelioma patients may benefit more from aggressive extrapleural pneumonectomy surgery than from the lung-sparing pleurectomy and decortication, which is currently the recommended alternative by many specialists.

According to the latest study from Italy, extrapleural pneumonectomy, or EPP, allowed mesothelioma patients diagnosed with high symptom burden to live longer and better quality than the more popular pleurectomy and decortication surgery, also known as P/D.

The Journal of Clinical Medicine on October 29 published the latest report written by specialists in thoracic oncology at the Policlinico of the University of Tor Vergata in Rome.

“Extrapleural pneumonectomy showed the most durable effects,” the study authors write. “Pleurectomy/decortication achieved some transient benefits in symptom control, particularly in the first few months after surgery, but we found more effective, long-lasting pain control after extrapleural pneumonectomy.”

Better quality of life with EPP

The study results, contrary to previous reports and a growing trend, were based on 55 patients with pleural mesothelioma in Rome who underwent one of the two major surgeries over a 14-year period. They were part of a multidisciplinary treatment plan.

Twenty-nine patients had EPP surgery and 26 had P/D surgery. Those with the EPP fared better overall.

The determinants of quality of life and symptoms were compared before mesothelioma surgery, then again three months, six months, 12 months, and 24 months after surgery.

Measurements included a six-minute walk, body pain, physical functioning, vitality, and mental health.

“The improvement in physical, social, and pain-related parameters measured was sustained over a longer period of time in the extrapleural pneumonectomy group,” the authors write. “Both procedures showed a three-month improvement in many symptoms and quality of life.”

No differences were found between the two surgeries in the chemotherapy and radiotherapy compliance rate, which was part of the overall treatment plan.

Median overall survival was 20 months for those with EPP and 13 months for those who received P/D surgery. At two years, five of the 26 P/D patients were alive compared to nine of the 29 EPP patients. After three years, only four EPP patients were still alive.

“Given the generally low life expectancy, quality of life plays a leading role,” the authors write. “These results confirm the effectiveness of extrapleural pneumonectomy in local disease control.”

More precise P/D Less risky

The study results contrasted with the growing belief among thoracic oncologists today that EPP surgery should be used infrequently because it is aggressive and has the potential for debilitating side effects.

Mesothelioma, a rare cancer caused by long-standing asbestos exposure, typically begins in the thin lining around the lungs and metastasizes throughout the chest cavity.

The P/D surgery, which is more detailed and precise but less life-changing than EPP, removes the lining around the lungs and any visible tumor cells throughout the chest cavity. The operation can last up to 10 hours.

EPP surgery can allow for more complete tumor resection. The pleural mucosa, the entire diseased lung and large parts of the diaphragm and pericardium are removed.

Less than a third of patients with pleural mesothelioma are even considered for surgery, as most are not diagnosed until the disease has progressed too far.

Most other studies have shown a small difference in median survival between the two procedures — ranging from 15 to 24 months — but most have concluded that quality of life worsens more with the more aggressive EPP.

dr David Sugarbaker pioneered EPP

EPP surgery, invented nearly 20 years ago by legendary thoracic surgeon Dr. Developed by David Sugarbaker, it is not used as often as it used to be. Many surgeons believe that the risks of such major surgery outweigh the benefits, making it less attractive.

However, despite the decline in usage, there have been wonderful success stories. One of Sugarbaker’s greatest accomplishments at EPP is Tim Crisler of Kennesaw, Georgia, who is considered America’s longest-living pleural mesothelioma survivor.

Crisler, 66, recently celebrated his 20th year of survival after surgery.

Sugarbaker died in 2018, leaving Crisler and his EPP operation as part of his legacy.