The Role of Video-Assisted Thoracoscopic Pleurectomy/ Decortication in the Therapeutic Management of Malignant Pleural Mesothelioma
Source: Nakas A, et al., The role of video assisted thoracoscopic pleurectomy/decortication in the therapeutic management of malignant pleural mesothelioma, Eur J Cardiothorac Surg (2007), doi:10.1016/j.ejcts.2007.09.039
Mesothelioma is among the most difficult cancers to treat effectively and no true cure exists for this asbestos-caused disease. However, there is an active and creative research community regularly exploring new therapies that hope to improve upon current mesothelioma treatments. Surgery is one of these active areas of research and doctors are regularly comparing mesothelioma surgical techniques in terms of their efficacy, survival time and recovery rate. Researchers from the United Kingdom have recently released the results of a study that looked at what the proper role of video-assisted thoracoscopic (VATS) pleurectomy/decortication should be in the treatment of malignant pleural mesothelioma.
Introduction to the Study
There are a number of surgeries in common use for the management of mesothelioma. They are generally split between two strategies: strictly palliative procedures, which only try to reduce the pain and increase the quality of life of a patient—but do not try to actually cure him or her, and life-extending procedures that aim to reduce tumor burden as much as possible to increase survival time and, ideally if not practically, to cure the patient of the disease. The two most common life-extending procedures used for the treatment of pleural mesothelioma are extrapleural pneumonectomy (EPP) and radical pleurectomy/decortication (Radical P/D). An EPP is defined as the en bloc resection (complete removal) of the affected lung, pleura, pericardium and diaphragm, with a corresponding reconstruction of the pericardium and diaphragm. A Radical P/D is similar to an EPP, but it leaves the lung intact. These procedures are associated with high morbidity, meaning they are prone to significant complications during and after surgery, and high mortality, which means there is a possibility that the patient may die during surgery or soon after it. They are still, however, the standard of care for certain patients because they offer the best chances to prolong survival.
The authors of the study compared these two procedures with video-assisted thoracoscopic pleurectomy/decortication (VATS P/D) to determine the overall efficacy of the procedure and to study what, if any, quality-of-life improvements arose for those who underwent it. The authors define a VATS pleurectomy/decortication as a pleurectomy of the parietal pleura and a decortication of the lung with removal of the visceral pleura. Unlike Radical P/D, the extrapleural areas are left intact. It is a debulking procedure designed to reduce tumor burden, but is considered more of a palliative procedure because it does not seek to remove all macroscopically-visible malignant tissue. It is a less radical procedure than either EPP or Radical P/D and is often given to older patients and/or to those who are unfit for the others.
The authors looked at the results of 208 patients who underwent surgery for pleural mesothelioma. 112 underwent an EPP, 29 had a Radical P/D and 67 had VATS P/D. 63 were over the age of 65 at the time of the operation and 42 of them underwent a VATS P/D. In terms of overall fitness, VATS P/D was given to those who did not quality for an EPP or Radical P/D.
In aggregating the study numbers, the authors discovered that for the over 65 group, 30-day mortality was much higher for EPP (23%-3 out of 13) than it was for Radical PD (12.5%-1 out of 8) and VATS P/D (7.1%-3 out of 42) . These mortality figures confirmed that, in at least some cases, VATS P/D showed a positive offset in the patients favor for a reduction in treatment morbidity due to less extensive tumor resection. The VATS P/D group had a significantly lessened post-operative hospital stay period as compared to the EPP group (14.3 days/avg. vs. 36.6 days/avg.), although it was slightly higher than the Radical P/D Group (14.3 day/avg. vs. 14 days/avg). The authors also found that mean survival for the over 65 group favored VATS P/D (14 months) over Radical P/D (12.4 months) and EPP (11.5 months).
The authors conclude that they will still offer EPP and Radical P/D to patients who are over 65, but that for those over 70 they are reluctant to offer EPP. For people who are not candidates for the other radical surgeries, they feel that VATS P/D is the only effective method available to palliate their situation. While VATS P/D has known quality-of-life benefits and appears to prolong survival in at least one subgroup of patients, they are not yet ready to conclude that it’s a truly effective treatment strategy and call for more research into the question.