MD Anderson Examines Aggressive Mesothelioma Surgery in Latest Study

A retrospective study involving two decades of pleural mesothelioma patients at the heralded University of Texas MD Anderson Cancer Center failed to demonstrate a definitive survival advantage to support regular use of extrapleural pneumonectomy surgery.

The most aggressive surgery possible for this type of mesothelioma – once the surgery of choice – showed no clear benefit over a more conservative procedure.

When compared to the less-aggressive, lung-sparing pleurectomy and decortication surgery, EPP had a much higher perioperative mortality rate and a shorter median survival.

“In a multimodality treatment paradigm, the type of cytoreductive operation for MPM does not define long-term outcomes,” the authors wrote. “We did not find type of operation to be associated with long-term oncological benefits in the overall cohort, or any patient subgroup that we examined. P/D is a much safer operative procedure.”

The Annals of Thoracic Surgery published the study earlier this month. Authors include oncologist Dr. Anne Tsao and thoracic surgeon Dr. David Rice, MD Anderson mesothelioma specialists in Houston.

Use of EPP Declining at Most Treatment Centers

MD Anderson’s status as the No. 1 ranked cancer hospital in America for seven consecutive years added considerable weight to earlier, less extensive studies that had reached similar conclusions and fueled the ongoing debate about whether EPP should continue to be performed.

When aggressive surgery is an option, most mesothelioma patients in recent years have been choosing the pleurectomy and decortication approach.

At MD Anderson, for example, 122 patients underwent EPP surgery from 2000 to 2006, compared to only 19 from 2014 to 2019. During the same period, the P/D numbers jumped from five to 48.

Extrapleural pneumonectomy surgery involves removing the entire diseased lung, the lining around it, parts of the diaphragm and pericardium.

The P/D, which was developed as a less-aggressive alternative, removes the pleural lining around the lung, all visible tumors on the lung and anywhere else in the thoracic cavity.

Although the goal with both is a complete tumor-cell reduction, it is much more difficult to achieve with the P/D surgery.

“Rather than focusing on which procedure is better, it appears that the goal should be to achieve MCR [macroscopic complete resection] using the safest operative method that the patient can tolerate,” the authors wrote.

Type of Surgery Doesn’t Define Long-Term Outcomes

The study involved 282 surgical patients at MD Anderson Cancer Center from 2000 to 2019, including 66% who had the EPP and 34% undergoing P/D.

It also found that, regardless of which surgery was used, epithelioid histology, macroscopic complete resection, adjuvant radiation therapy and more recent operative years were associated with better survival.

Of the 21 perioperative deaths with EPP surgery, seven were attributed to cardiac arrest, six to respiratory failure and five from infection.

EPP patients typically were younger, had a lower median performance status score and were more likely to be smokers.

Perioperative death rates with EPP have varied widely in earlier studies. Renowned thoracic surgeon Dr. David Sugarbaker, who pioneered the procedure at Brigham and Women’s Hospital 20 years ago, reported a 3%-5% mortality rate in his study, but others have reported mortality as high as 18%.

Still A Place for Extrapleural Pneumonectomy

While most earlier studies had similar findings to MD Anderson’s – leading to the significant drop in EPP surgeries in recent years – there has been one definitive exception that continues to intrigue surgeons who still believe in the procedure.

The Princess Margaret Cancer Center in Toronto has taken an unconventional approach that involves tumor-priming, high-dose radiation before the EPP surgery.

Researchers there reported a three-year survival rate of 58%, including an 84% survival rate for those with the epithelial mesothelioma subtype.

Conversely, most multidisciplinary treatment centers in the U.S. start with chemotherapy before aggressive surgery and end with radiation, if used at all.

“Future trials in operable mesothelioma should use P/D as the main surgical approach in order to achieve the goal of cytoreduction and to return patients to potential additional oncologic therapy,” the study concluded.