The question of whether
extrapleural pneumonectomy (EPP) is superior to supportive care, in terms of morbidity,
symptom control and survival, in the treatment of patients with malignant pleural
mesothelioma (MPM) is examined by reviewing 14 papers best demonstrating
the evidence to answer this question. After relevant outcomes and results
were tabulated, this study concludes that EPP confers no advantage to
chemotherapy and palliative treatment in terms of survival and symptom improvement.
According to the study, the median survival was 13 months, 5.7% perioperative
mortality rate and 9.1% 30-day mortality rate. There was a high morbidity
rate of 37% during
surgery due to the following factors: atrial fibrillation, empyema and supraventricular
arrhythmias. Disease recurred in 73% of patients at a median time of 10
months. Median hospital stay was 13 days and intensive care unit stay
was 1.5 days. At three months post-surgery, improvement in symptoms was
achieved in 68% of patients, with significant advantages observed in patients
with epithelial MPM compared to non-epithelial MPM.
Management of MPM may include the use of chemotherapy or surgery with
palliative intent. However when the EPP is used with curative intent,
studies show that is likely to fall short of expectations. The clinical
bottom line to this study is that EPP is a highly morbid operation with
high perioperative mortality and recurrence rate. Although a number of
retrospective studies have shown a small benefit in survival with EPP,
there is consensual agreement that even in subgroups with the best prognostic
indicators, such as epithelial histology or negative lymph node metastasis,
EPP still results in high complication rates with minimal symptomatic
improvement.
The MARS trial, which clearly demonstrates the detrimental effects of
conducting EPP surgery compared to conservative management, is especially
significant. This study also reported that lung-sparing radical decoration
surgery tends to produce higher median survival rates compared to palliative surgery.