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Pleurectomy-decortication (P/D) was first popularized in the mid 1950s as a surgical method for treating entrapped lung that developed as a complication of tuberculous empyema. P/D evolved as a treatment for a variety of lung pathologies including other infectious empyemas, effusive metastatic disease, and pleural metastases. As diffuse malignant pleural mesothelioma (MPM) came to prominence in 1960, when Wagner and coworkers described MPM in asbestos mine workers from South Africa,
P/D was one method adapted and utilized for treating MPM. A rare disease with an incidence of just under 1 per 100,000 in the United States, cases of MPM have increased since the 1970s with an estimated 2000 to 3000 new diagnoses in America each year.
Today, MPM remains a lethal cancer without consensus regarding optimal staging and treatment. In particular, the role of surgical resection in MPM and, specifically, the choice of extrapleural pneumonectomy (EPP) versus P/D, remains highly controversial.
P/D is an attempt to remove all gross disease without removing the underlying lung and involves resection of the parietal pleura, visceral pleura, the pericardium, and, in roughly 50% of patients, the diaphragm. Macroscopic evidence of involvement of the pericardium requires resection and reconstruction; however, diaphragmatic disease can often be successfully stripped from the surface of the diaphragm without formal resection and reconstruction.
Indications and Contraindications
MPM was universally thought to be fatal in the era before effective systemic therapy. Surgery was primarily used for diagnostic or palliative purposes. In 1976, Butchart and colleagues reported their experience with EPP for MPM and documented durable long-term survival, yet a 33% operative mortality.
illustrating that high-volume centers could perform EPP safely. Nonetheless, the high mortality and morbidity associated with EPP, and the well-known complications of pneumonectomy, led some surgeons toward P/D. The mortality of P/D is 1.0% to 4.0% and to date there is no evidence showing superiority of EPP over P/D.
Regardless of technique, certain fundamentals hold true: surgery is a key component in the treatment of MPM and achieving a macroscopic complete resection is the goal. Indications supporting P/D over EPP can be related to either patient or tumor characteristics. In patients with insufficient cardiopulmonary reserve for pneumonectomy, a postoperative predicted forced expiratory volume in one second or a diffusing capacity of the lung for carbon monoxide of less than 40%, or a left ventricular ejection fraction of less than 45%, P/D is clearly indicated. In early stage disease, confined to the parietal pleura (Butchart I, IMIG T1a) or confined to parietal and visceral pleura without involvement of underlying lung parenchyma (IMIG T1b), P/D provides clearance of disease without the additional morbidity or mortality of a pneumonectomy.
In patients with confluent sheets of tumor involving the entire lung and obliterating the pleural space, P/D is unfeasible and EPP should be considered. Computed tomographic (CT) scans may provide preoperative evidence of this level of tumor involvement, but often this decision is made intraoperatively. MPM is a disease where a true R0 resection is impossible and surgical therapy provides removal of gross tumor as a foundation for adjuvant therapy. With this perspective, P/D may limit adjuvant therapy by limiting the dose of radiation used in the postoperative hemithorax. However, with newer methods of radiation administration such as intensity modulated radiation therapy and encouraging results with systemic chemotherapy, residual lung parenchyma left after P/D may not alter adjuvant therapy as much as previously thought and may protect the patient from the morbidity of a pneumonectomy.
Imaging of the chest and upper abdomen with CT is mandatory. If chest wall or neurovascular invasion is suspected, MRI may be helpful in preoperative planning. Positron emission tomography/CT is done to screen for distant metastatic disease and the standard uptake value can be used to predict the presence of N2 lymphatic spread.
Although N2 disease does impart a worse prognosis in MPM, it should not be used as an absolute criteria denying surgical resection. Therefore, there is no absolute indication for preoperative mediastinoscopy. Ventilation/perfusion scans are helpful in cases where pulmonary function tests (PFTs) are questionable or the extent of pleural disease significantly alters the patient's ability to perform for the PFTs and a more accurate assessment of lung function is needed. Patients with postoperative predicted values of greater than 40% are considered acceptable for either EPP or P/D.
P/D is a safe procedure with mortality limited to approximately 1 to 4%. The most common postoperative complication is prolonged air leak (air leak lasting more than 7 days), which occurs in upward of 10% of cases. Continued chest tube drainage is sufficient in a majority of cases as the air leaks will seal over time. Pleurodesis is reserved for air leaks that fail simple chest tube drainage and good expansion of the lung parenchyma is observed on chest x-ray. Rarely, continued air leaks are managed with a BD Bard-Parker Heimlich Valve (BD, Franklin Lakes, NJ). In these cases, all but 1 chest tube is removed after sequential clamping and serial chest x-rays document adequate lung expansion. Median survival time ranges from 9 to 20 months. The literature shows that surgery alone is insufficient therapy and results in rapid relapse of disease.
Suboptimal cytoreduction is believed to be the cause. Irrespective of procedure, EPP or P/D, a complete R0 resection is impossible because microscopic disease is invariably left behind. Therefore, most treatment regimens have focused on multimodality approaches combining a surgical procedure for cytoreduction with chemotherapy and radiation in a multimodality setting. The majority of recent studies have described either EPP or P/D in combination with neoadjuvant or adjuvant chemotherapy, intrathoracic chemotherapy, adjuvant external beam radiotherapy or intensity modulated radiation therapy, intraoperative radiotherapy, or brachytherapy. Due to small sample sizes and comparatively heterogeneous groups, a consensus on treatment strategies and conclusions regarding optimal therapy remain lacking.
In the largest study to date, Flores and coworkers analyzed 663 MPM patients from 3 different institutions and compared overall 5-year survival. A total of 385 patients were identified who underwent EPP and 278 patients who underwent P/D. Of these patients, a statistically significant number of early stage (I-II) patients favored P/D, whereas a statistically significant number of patients favored EPP due to younger age and having received multimodality therapy. In univariate analysis, P/D was associated with a significantly better median survival than EPP (P < 0.001). However, in a multivariate analysis by a Cox proportional hazard model that controlled for histology, stage, gender, and multimodality therapy, EPP had only a modestly higher hazard ratio of 1.4 when compared with P/D. Of note, operative mortality was 7% in the EPP group and 4% in the P/D group with a higher proportion of EPP patients experiencing serious respiratory complications (10%) compared with the P/D cohort (6.4%).
Until a randomized controlled trial is completed, current therapy remains controversial with the choice of P/D or EPP directed by a combination of disease characteristics, patient characteristics, and surgeon discretion.
Diffuse pleural mesothelioma and asbestos exposure in the north Western Cape Province.