It is essential that patients receive a careful assessment before Mesothelioma surgery is performed. Surgical resection for patients with MPM can include either 1) pleurectomy/decortication (P/D; also known as total pleurectomy, lung-sparing surgery), which is complete removal of the involved pleura and all gross tumor; or 2) extrapleural pneumonectomy (EPP), which is en-bloc resection of the involved pleura, lung, ipsilateral diaphragm, and often the pericardium (see Principles of Surgery in the NCCN Guidelines for Malignant Pleural Mesothelioma). Extended P/D refers to the resection of the diaphragm and pericardium in addition to total pleurectomy.
Mediastinal nodal dissection is recommended in patients having either P/D or EPP; at least 3 nodal stations should be obtained (see the NCCN Guidelines for Non-Small Cell Lung Cancer, available at NCCN) The surgical goal for MPM is cytoreductive Mesothelioma surgery to achieve macroscopic complete resection by removing all visible or palpable tumors. If macroscopic complete resection is not possible—such as patients with multiple sites of chest wall invasion—then surgery should be aborted. However, surgery should be continued—if most of the gross disease can be removed—to help with postoperative management and if there will be a minimal impact on morbidity.
The choice of surgery for MPM is controversial, because data from randomized controlled trials are not available. Neither EPP nor P/D will yield an R0 resection. EPP would often be required to remove all gross tumor in patients with stages II to III MPM (epithelial histology). However, EPP is associated with higher morbidity and mortality. P/D (ie, lung-preserving surgery) is safer than EPP.
A retrospective analysis (n = 663) suggested that survival was greater after P/D than after EPP, but this may have been confounded by patient selection. A meta-analysis suggested a trend in favor of overall survival for extended PD when compared with EPP. Lung-sparing options, such as P/D, reduce the risk for perioperative mortality when compared with EPP and yield either equal or better long-term survival than non-surgical therapy in patients with more advanced disease.
A feasibility trial (Mesothelioma and Radical Surgery [MARS]) assessed whether patients treated with induction chemotherapy would accept randomization to EPP or no surgery; 112 were patients enrolled in the trial, and 50 patients were randomized. The authors concluded that due to the observed high rate of surgical mortality, EPP was not beneficial when compared with chemotherapy treatment alone.
However, these results were controversial because survival was not the primary outcome of the study, the sample size was small, and the surgical mortality was higher than expected. An Australian retrospective study (540 patients) reported that several factors yielded increased survival for select patients, including EPP, surgeon experience, and treatment with pemetrexed.
The NCCN Panel feels that P/D and EPP are reasonable surgical options that should be considered in select patients to achieve complete gross cytoreduction. Although P/D may be safer than EPP, it is not clear which operation is oncologically better. When surgery is indicated, the choice between P/D and EPP should be made based on several factors including tumor histology and distribution, pulmonary reserve, surgical experience and expertise, and availability of adjuvant and intraoperative strategies. In patients who are medically operable, the decision about whether to do a P/D or an EPP may not be made until surgical exploration. P/D may be more appropriate for patients with advanced MPM who cannot tolerate an EPP. P/D may also be useful for symptom control (eg, patients with entrapped lung syndrome, recurrent pleural effusions).
The NCCN Panel does not recommend Mesothelioma surgery for patients with stage IV MPM, sarcomatoid histology, or mixed histology; chemotherapy is recommended for these patients (see Chemotherapy in this Discussion and Treatment in the NCCN Guidelines for Malignant Pleural Mesothelioma). In addition, surgery is generally not recommended for patients with N2 disease unless performed at a center of expertise or in a clinical trial.