Encouraging Results for Lung-Sparing Surgery in Pleural Mesothelioma

Malignant pleural mesothelioma (cancer of the lung lining) patients were found to benefit from the surgical approach of pleurectomy decortication (stripping the lung lining) if all visible tumors could be removed, known as macroscopic complete resection, with longer overall survival. These findings were reported on December 3, 2020, in Annals of Surgery from a retrospective study.

Pleural mesothelioma is an aggressive cancer of the pleura, the membrane covering the lung surface; it results predominantly from previous asbestos exposure. 

The United States National Comprehensive Cancer Network (NCCN) guidelines for mesothelioma diagnosis and treatment recommend multimodality treatment (an approach involving multiple interventions), including achieving surgical macroscopic complete resection. Systemic therapies (chemotherapy and immunotherapy) are regarded as the mainstay of treatment for this disease.

For mesothelioma treatment, extrapleural pneumonectomy involves removing a lung, the parietal pleura (outer lung lining), and parts of the pericardium (heart lining) and diaphragm, making it extensive / radical surgery. An alternative surgical procedure for mesothelioma is lung-sparing surgery, pleurectomy decortication, which involves removing the parietal (outer) and visceral (inner) pleura and visible tumor masses. Extended pleurectomy decortication also involves surgically removing the pericardium and diaphragm on the same side.

Although evidence indicates that pleurectomy decortication and extended pleurectomy decortication are increasingly preferred to extrapleural pneumonectomy for surgical treatment of mesothelioma, this study aimed to evaluate short- and long-term outcomes and factors affecting disease prognosis.

The analysis was based on medical-record data from 355 consecutive mesothelioma patients scheduled for pleurectomy decortication at a single cancer center between 2007 and 2015.

The most common postoperative complications were not life-threatening and, in order of frequency, were prolonged air leak (46.5%), deep vein thrombosis (21.1%), atrial fibrillation (13.9%), lymphatic fluid leakage (7.9%), empyema (7.6%), and pneumonia (6.9%). Mortality at 30 and 90 days was 3% and 4.6%, respectively.

Patients whose visible tumors were completely removed with this surgery had a median overall survival of 23.2 months, compared with 11.6 months in those without complete removal (P <.0001).

In the complete surgical resection group, male sex (hazard ratio [HR], 1.79; compared with female sex; P = .002) and higher tumor stage (compared with T1, HR for T3, 2.31: P <.001) were factors adversely affecting prognosis. Conversely, adjuvant chemotherapy (HR, 0.45 vs no adjuvant chemotherapy; P <.001), intraoperative heated chemotherapy (HR, 0.60; P = .024) and epithelioid histology (HR, 0.62 vs biphasic histology; P = .003) were associated with better disease outcomes.

Conclusion

Although conducted at a single center, the patient number exceeding three hundred made the statistical analyses and study power satisfactory. This study confirms that pleurectomy decortication can be performed with low 30- and 90-day mortality.

This surgical procedure also makes multimodality treatment more feasible for patients with mesothelioma.

In 2020, both FDA approval of combined (dual) immunotherapy and this study's demonstration of the safety and effectiveness of lung-sparing surgery were important developments in expanding promising treatment options for mesothelioma.

This approach supports the role of surgery in mesothelioma treatment and provides a foundation for future comprehensive, multicenter trials with randomized patient recruitment.

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• Related topic: What is mesothelioma? Its history and the current state of treatment