Clapper, Patti, Schweizer and Mason

The most effective therapeutic approaches to managing mesothelioma combine multiple treatment modalities.  Since mesothelioma is often not diagnosed until very advanced stages, using aggressive strategies can be risky yet lead to higher survival times and increased overall quality of life.  The benefits as well as drawbacks of using different modalities must be weighed against stage, histology, performance status, etc. before creating a treatment plan.

The three standard mesothelioma treatment modalities are:  surgery, chemotherapy and radiation therapy.  If the patient’s condition allows, surgical resection will be the first intervention before others are introduced.  For surgical cytoreduction to be a feasible option, certain criteria must be met:

1.      Overall patient health must indicate that surgery can be performed safely, including nutritional health, performance status, pulmonary function levels, extent of disease and histology subtype

2.      Malignancy is localized, increasing chances of complete tumor removal

3.      Informed patient consent, including understanding of risks and investigational versus curative nature of procedures

For pleural malignancies such as mesothelioma, surgery usually includes extrapleural pneumonectomy (EPP) or pleurectomy/decortication (P/D) followed by either radiation or chemotherapy.  EPP involves removal of the thin membrane of tissue that covers the lungs and heart, the lung, and surrounding diaphragm muscle.  Best results are seen with single incision of the 6^th rib, pericardial and diaphragmatic reconstruction and epithelial types of mesothelioma.  EPP is almost always followed with adjuvant therapy of chemotherapy using cisplatin-gemcitabine and/or external beam radiation.   

P/D is a less intense surgical procedure that leaves the lung intact and only involves removal of the tumor and pleura.  The procedure of separating the tumor from the lung versus complete removal takes more time yet carries a lower mortality rate while still enhancing quality of life. 

The best way to minimize surgical complications and improve patient outcome is to ensure good patient selection, attention to detail during surgery, and awareness and immediate treatment of any postoperative complications if they occur.  Recurrence is known to occur, with the most common site being the thoracic cavity.  Aggressive adjuvant therapies are needed to lower the high local recurrence rates. 

Despite risks, survival benefit makes surgical cytoreduction combined with post-adjuvant therapies worth considering for anyone diagnosed with mesothelioma, especially early stage disease.  For current clinical trials being conducted at the National Cancer Institute involving surgery for eligible patients visit:  http://clinicaltrials.gov/ct2/show/NCT01134146.