Arguments for Each: P/D Surgery versus EPP Surgery

Argument 1:  In Favor of Pleurectomy/decortication (P/D) for Mesothelioma

In addition to site-specific cyto-reductive surgery, doctors have for years performed radical and extremely dangerous extrapleural pneumonectomies (EPP) on mesothelioma. The procedure, which includes the removal of the entire lung, the diaphragm, and the membrane surrounding the heart, has been controversial—to say the least—and several studies have pointed out the high mortality rate and the lowered quality of life in patients who undergo this last-ditch surgery as reasons to discontinue its use.

However, a similar but less invasive surgery is growing in popularity among mesothelioma doctors who advocate surgery for their patients. Pleurectomy/decortication (P/D) is a procedure which includes the removal of the pleura—the soft tissue membrane that surrounds the lungs. The procedure leaves the lungs and diaphragm intact and has displayed some promising results.

In fact, in an editorial published in the April 2012 edition of the Journal of Thoracic Oncology, Dr. Michael Weyant wrote an impassioned piece advocating this surgery as an alternative to the more dangerous procedure.

Weyant wrote that mesothelioma patients who do choose to undergo this procedure tend to live longer and have a much higher quality of life than their counterparts. Weyant drew on a study which examined two groups of several mesothelioma patients who underwent either procedure in addition to chemotherapy between January 2008 and June 2011.  The data showed that those who underwent the less invasive procedure of pleurectomy/decortication outlived the others and were healthier overall.

In fact, two years after their surgery, a full half of the P/D patients were still alive compared to only 18% of those who underwent the full extrapleural pneumonectomy. That survival ratio was carried over to the 5-year benchmark as well: 30% of the P/D patients were still alive when compared to just 9% of the EPP patients.

However, Weyant recognized that some mesothelioma patients could be better treated through EPP. The decision, he argued, should ultimately be made on a case by case basis where both the mesothelioma surgeon and the patients weigh the risks, the rewards, and their expectations for the remainder of their lifespan prior to determining which option would best suit them.

As is the case so often, mesothelioma is a very personal disease. It affects everyone differently and a number of factors including prior medical history, current health statistics, and future expectations come into play when deciding on the proper course of treatment.

However, the case for P/D is growing as EPP becomes less and less popular overtime. A Recent MARS study concluded that often the risks associated with EPP (including the greatly increased death rate up to six months after the surgery) outweigh the benefits. Many doctors have begun to see extrapleural pneumonectomies as a last-ditch effort to prolong life no matter the risk.

Regardless of the type of surgery, or even whether surgery is an option at all, many mesothelioma patients still must undergo multiple rounds of chemotherapy and radiation treatments to combat this horrible disease. Currently, there are roughly 3,000 new cases of mesothelioma diagnosed every year in the United States.

Argument 2:  In Favor of Extrapleural Pneumonectomy (EPP)

Doctors and scientists alike continue to debate the safety and merits of extrapleural pneumonectony (EPP) for mesothelioma patients. While some studies seem to conclude that the radical surgical procedure is too risky, doesn’t produce the sort of results it should, and can be replaced by other relatively new surgical procedures, some still see this procedure as the best option for certain pleural mesothelioma cases.

Extrapleural pneumonectomy is a procedure during which surgeons remove all of one lung and portion of the membrane surrounding the other. While the chest cavity is open, the surgeons also look for other diseased tissue and often end up removing portions of the membrane surrounding the heart and parts of the diaphragm as well. Because the procedure is so radical, patients often require extended stays in the hospital during recovery and can take anywhere from six weeks to several months to fully recuperate. The surgery also comes with a greatly increased death rate both during and immediately after the procedure as well.

The latest group of researchers to enter the debate comes from the Department of Thoracic Surgery at Tor Vergata University in Rome. The group’s initial assumption was that the clinical impact of EPP hadn’t been fully explored and that perhaps “experts” were forming the contradictory opinions without have enough data to work with.

The researchers retrospectively examined the individual cases of 29 mesothelioma patients who underwent this surgery between 1997 and 2007. The data they looked at included the results of multiple tests through which the patients were monitored after surgery. These included:

• Spirometry – to test lung capacity
• Arterial blood gas analysis – to record the level of oxygen and carbon dioxide in the blood
• 6-min walk test – to test the patient’s overall resilience
• Echocardiographic tests – to assess the overall health of the heart muscle

Patients were also asked a number of self-assessment questions to better help their doctors understand what they were feeling subjectively. These included questions about their level of pain, shortness of breath, and any other symptoms (such as cough of fever) they thought might be related to the procedure. A standardized quality of life test was also used to get a baseline to use a measure of improvement over time.

Within this group of patients only one died immediately after the surgery. However, 41% of the remaining patients suffered some form of morbidity (disease or illness related to the surgery.)   As far as postoperative survival rates, the study results fell in line with others that had previously examined EPP patients. The average survival rate across the whole population was just 19.5 months.

Interestingly enough, all of the testing and self-assessment measures remained stable for a period of 12 months after surgery. These figures then progressively got better except for the level of pain and shortness of breath that the patients were reporting. These two factors remained below baseline post-surgical testing for over 24 months in those patients who survived for this time period.  Another noted point was that patients whose self-assessment testing indicated that they had a better attitude and overall outlook on the remainder of their lives actually fared better with fewer and less adverse reactions.

This data led the Italian researchers to conclude that despite the controversy surrounding this radical procedure, and the high morbidity rates associated with it, EPP “has a significant and durable impact on function and symptoms as well as on physical and mental components of quality of life in patients with malignant pleural mesothelioma.”

If you or a loved one has been diagnosed with asbestos cancer, a mesothelioma doctor or specialist is the one who will be able to go over your surgical options and the risk factors associated with each.   As always, any course of treatment must be tailored to fit the individual patient. Therefore, while one patient may benefit from a less-aggressive treatment such as P/D, the next may have better results with EPP.