The state of the art in the technical performance of lung-sparing operations for malignant pleural mesothelioma

Our plain-English summary of The state of the art in the technical performance of lung-sparing operations for malignant pleural mesothelioma, by J.S. Friedberg (Seminars in Thoracic and Cardiovascular Surgery, 2013).

The study

• Author: J.S. Friedberg
• Journal: Seminars in Thoracic and Cardiovascular Surgery
• Published: 2013;25(2):125-43
• Type of article: Review
• Cited by: 21 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Malignant pleural mesothelioma remains an incurable disease for which the role of surgery remains controversial. Though not yet clearly defined there does appear to be a subset of patients who benefit from a surgery-based multimodal treatment plan, beyond what would be expected with current nonoperative therapies. As with other pleural cancers it is probably not possible to achieve a microscopic complete resection with any operation. The goal of surgery in this setting, therefore, is to remove all visible and palpable disease - a macroscopic complete resection. There are basically two surgical approaches to achieve a macroscopic complete resection, lung-sacrificing and lung-sparing. Lung-sacrificing surgery, which likely leaves behind the least amount of microscopic disease, is accomplished as an extrapleural pneumonectomy. This is a well established and standardized operation. Lung-sparing surgery for malignant pleural mesothelioma, on the other hand, does not currently enjoy any degree of consistency. Not only are the reported variations on the operation widely disparate, but even the nomenclature to describe the operation is highly variable. Often the selection of a lung-sparing approach is reported as an intraoperative decision that hinges on the bulk of the cancer and/or the degree of extension into the pulmonary fissures. This article describes the current evolution of a lung-sparing procedure, radical pleurectomy, which has been used to achieve a macroscopic complete resection in over a hundred patients. Many of these cases involved bulky cancers, some exceeding two liters in volume, and often with extensive invasion of the pulmonary fissures. With the described technique there has not yet been an instance where conversion to extrapleural pneumonectomy would have contributed to the ability to achieve a macroscopic complete resection. Whether or not radical pleurectomy is the optimal approach for any or all patients undergoing surgery-based multimodal treatment for malignant pleural mesothelioma is not known, but the described technique does offer an operation that can serve as a consistent foundation for any surgery-based treatment strategy where achieving a macroscopic complete resection, while sparing the lung, is desired.

Copyright © 2013. Published by Elsevier Inc.

In plain English

This is a surgical 'state of the art' paper, not a study of asbestos exposure. The author described, step by step, a lung-sparing operation for malignant pleural mesothelioma called radical pleurectomy. It removes all pleural surfaces, including the lining of the lung, while keeping the lung. The goal was a macroscopic complete resection: removal of all visible and palpable cancer. The author reported preserving the lung in more than a hundred of these operations, often with bulky cancers exceeding a liter. The author reported no case where switching to extrapleural pneumonectomy (removing the lung) would have changed whether the cancer could be removed. The article also summarized the author's earlier published series of 38 patients, 97% at stage III or IV. Macroscopic complete resection was achieved in all but one, and one patient died after surgery from a stroke. Overall median survival from surgery was 31.7 months: 41.2 months for 31 patients with epithelial subtype and 6.8 months for 7 with mixed subtypes. The author stated that rigorous conclusions about the surgery's effectiveness are nearly impossible to draw.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: State-of-the-art review and description of the author's own surgical technique (radical pleurectomy), with a summary of the author's previously published patient series
• Who was studied: Patients with malignant pleural mesothelioma operated on by the author (University of Pennsylvania, Philadelphia) over about 15 years: more than 100 lung-sparing operations, including an earlier published series of 38 patients
• Exposure: No asbestos exposure was studied. The article is about surgery and mentions asbestos only as background on the cause of the disease.
• Main results:
  • The author preserved the lung in more than a hundred radical pleurectomy operations, often with cancers exceeding a liter in volume
  • Using the described techniques, macroscopic complete resection on the lung was reported as technically possible in every case
  • In the author's earlier series of 38 patients, 97% were stage III or IV
  • In the 38-patient series, macroscopic complete resection (removal of all visible and palpable disease) was achieved in all patients but one, and there was one postoperative death, due to stroke
  • In the 38-patient series, overall median survival from the time of surgery was 31.7 months
  • By subtype, median survival was 41.2 months for the 31 of 38 patients with epithelial subtype and 6.8 months for the 7 of 38 with mixed subtypes
  • Diaphragm rupture occurred in 3 patients after events that led to uncontrolled straining
  • The author never had to reoperate on a patient for a persistent air leak
• The authors' conclusion: The author concluded that it appears technically possible to achieve macroscopic complete resection with lung-sparing surgery in essentially any case where it could be achieved with extrapleural pneumonectomy. The author also stated that whether radical pleurectomy is the optimal approach is not known.
• Limitations the authors state:
  • The author stated that it is nearly impossible to draw rigorous conclusions about the contribution and effectiveness of the surgery
  • The author stated it is unknown whether extrapleural pneumonectomy would have produced better survival
  • The author acknowledged that extrapleural pneumonectomy almost certainly achieves a more complete microscopic resection
  • The author stated that some technical features of the operation rest on assumption or intuition rather than data
  • The author stated that the effectiveness of the intraoperative photodynamic therapy used alongside the operation has not been established

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: State-of-the-Art Defense, Pleural Mesothelioma, Extrapleural Pneumonectomy (EPP).

Related studies

• Improved Outcomes with Modern Lung-Sparing Trimodality Therapy in Patients with Malignant Pleural Mesothelioma — F. Shaikh, M.G. Zauderer, et al. (2017)
• Thoracic shaping technique to avoid residual space after extended pleurectomy/decortication — S. Bölükbas, M. Eberlein, et al. (2013)
• Non-incisional pleurectomy-decortication for malignant pleural mesothelioma — F. Tanaka, N. Imanishi, et al. (2018)
• Factors predicting poor survival after lung-sparing radical pleurectomy of IMIG stage III malignant pleural mesothelioma — S. Bölükbas, M. Eberlein, et al. (2013)
• Optimal gross tumor volume definition in lung-sparing intensity modulated radiotherapy for pleural mesothelioma: an in silico study — A. Botticella, G. Defraene, et al. (2016)
• Lung-sparing total pleurectomy: the surgical option of choice in malignant pleural mesothelioma? — D.A. Waller (2013)

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