Type of Surgery for Mesothelioma
I was diagnosed with early-stage mesothelioma about 7 months ago and underwent surgery and chemotherapy. All of the cancer was removed during surgery, and I recently finished my chemotherapy. My last CT scan showed that I am cancer free. The surgery that I had removed my entire lung and has left me with some trouble breathing when moving a lot or climbing stairs. Although I am happy about my results so far, I just read that there is another surgery for mesothelioma that can save the lung. Did I have the correct procedure?
Charles B. Simone, II, MD, Radiation Oncologist at Penn Medicine, responds:
The type of surgery for mesothelioma that you had that removed the entire lung is called an extrapleural pneumonectomy and is the most standard way to treat early-stage mesothelioma in patients who are surgical candidates. Unfortunately, either due to a more advanced disease stage or medical comorbidities that makes the risks of surgery too high, only about 15% of patients with mesothelioma undergo an aggressive surgery that attempts to prolong survival. As an alternative to an extrapleural pneumonectomy, patients can undergo a pleurectomy, which is the removal of sites of bulky tumor that are typically symptomatic (causing pain or fluid to accumulate in the lung) and the adjacent lining of the lung. This is typically done as a palliative surgery in older patients or patients with more advanced disease that are not candidates for extrapleural pneumonectomy.
However, a more aggressive lung-sparing surgery, often termed radical pleurectomy or extended pleurectomy, is increasing in popularity and is probably what you read about. In this procedure, all visible tumor is removed, as well as the entire lining of the lung, even the lining that is not thought to be involved with disease. The lung, however, is spared and not removed. Early reports from the University of Pennsylvania, as well as centers in Germany and England, have shown very promising results with this procedure and achieved survival times that are longer than have been reported for extrapleural pneumonectomy series. This lung-sparing surgery also has the benefits of somewhat fewer perioperative complications and may allow patients to have better quality of life and breathing than if the lung was removed, which can allow patients to be better able to tolerate any subsequent therapy that may be needed if the cancer recurs. The lung-sparing surgery is a technically harder procedure for surgeons to perform, and it is being done in fewer centers than the more standard extrapleural pneumonectomy, but its use over the past 5 years is increasing. In fact, a new randomized trial comparing chemotherapy alone to chemotherapy and surgery that is beginning throughout Europe that plans to enroll 282 patients with mesothelioma is using the lung-sparing extended pleurectomy as the surgery of choice for the study.
The best results ever reported for mesothelioma, however, was for patients with stage I disease who have undergone an extrapleural pneumonectomy. Thus, experts disagree and the verdict is not in as to which surgery should be performed and considered standard. As data on the lung-sparing surgery matures and it is increasingly used, one procedure or the other may emerge as the preferred surgical approach in the future. For now, everyone agrees that the goal of surgery, whether the lung is removed or spared, is to remove all visible disease, as you had done. This is associated with the best survival among patients undergoing definitive surgery.