extrapleural pneumonectomy (EPP) was the preferred surgical approach to the management of malignant
pleural mesothelioma (MPM), physician and patient preferences have contributed
to an increased number of lung-sparing
pleurectomy/decortication (P/D) surgeries now being performed. Given the growing body
of research and when patients face the option of a less extensive
surgery that is equally or more effective than the EPP, has caused this dramatic
impact in thoracic surgeon practice patterns.
The P/D involves resection of the pleura but leaves the uninvolved lung
intact. It is already associated with less morbidity during surgery and
increased life-expectancy. The EPP has been well studied in the multimodality
paradigm and has shown that many patients are unable to tolerate post-operative
chemotherapy. Given these challenges, many investigators are exploring how best to
incorporate P/D into a multimodality treatment program.
This study examined the value of EPP versus P/D in a retrospective analysis
of 667 patients. Early data suggests that since adjuvant therapy is more
tolerable in P/D patients, multimodality therapy with P/D is associated
with improved survival. Treating MPM patients with intact lungs with pleural
intensity modulated radiation (IMRT) is feasible and safe and is associated
with encouraging survival rates in this retrospective cohort.
In conclusion, MPM patients clearly benefit from a multimodality approach,
but the optimal combination of surgery, chemo and radiation merits more
investigation. As more patients undergo P/D surgery instead, the EPP-centric
multimodality paradigm is shifting to integrate this trend. Researchers
are also currently evaluating a novel paradigm of preoperative chemo followed
by P/D and pleural IMRT in a prospective phase II trial.