Most of the patients coming to the office of Dr. Wickii Vigneswaran are older, such as 70s or 80s. So when they see him at Loyola University Health System, malignant mesothelioma isn’t their only health concern.
Dr. Vigneswaran and other mesothelioma doctors must take these co‑morbidities into account. They can affect the best course of action for treatment.
This plays a central role in which mesothelioma surgery to use: extrapleural pneumonectomy or pleurectomy/decortication. For many of these older patients, Dr. Vigneswaran has a clear‑cut answer.
“Most of my patients do better with pleurectomy and decortication,” he said. “The morbidity is much less compared to extrapleural pneumonectomy.”
Explaining the Differences Between P/D and EPP
Pleurectomy/decortication, or P/D for short, spares both lungs despite mesothelioma forming in the lining of the lung cavity (pleural mesothelioma). P/D involves removing this lining (pleura) plus the diaphragm and sac around the heart.
Extrapleural pneumonectomy, or EPP for short, takes out the lung affected by tumors. It’s a radical surgery and leaves the patient with only one lung. The idea is to do as much as possible to clear all tumors from the body.
However, mortality from EPP surgery is more than double mortality from P/D surgery. The 30‑day mortality rate after P/D surgery is between 1% and 3%. For EPP, the rate is up to 7% in some studies. Morbidity is also much lower. So is the recovery time from surgery.
For patients who survive surgery, EPP often causes difficulty breathing and other respiratory issues due to just one lung trying to handle the work of two. So their quality of life takes an unfortunate hit.
“The long‑term outcome is not much different,” Dr. Vigneswaran said.
Why EPP Works for Younger Patients
This is all especially true for older patients with stage 2 or stage 3 disease. The potential for a cure — removing all tumors from the chest cavity — is close to impossible. The hope is removing enough of the larger tumors near and on the lungs will add multiple years of survival.
For younger patients — age 60 and younger — with an early stage disease, EPP is more beneficial. They are more likely to live comfortably with only one lung, and the confined spread of tumors in stage 1 or stage 2 means a cure is possible. Removing one of the lungs is to ensure no tumors are left behind.
“If I can aim for a cure, at least to my satisfaction, and they’re young, I’ll consider (extrapleural pneumonectomy),” Dr. Vigneswaran said. “… “I think there are very few patients who you can try for a cure. It’s such a small percentage.”
This thought process is inverted from the traditional way of using EPP and P/D for mesothelioma. Since P/D doesn’t remove the lung, most doctors feel it’s best for early stage cancer since the tumors haven’t overrun the organ. EPP is considered best for later stages since tumors have spread more and put the lung in jeopardy.
“It’s just my philosophy,” he said. “I feel it has worked really well for us here at Loyola Health, but it’s just one way of viewing it. I just think our data on mortality backs up the approach.”
Comparing Survival Outcomes
“There doesn’t seem to be much difference in the overall survival,” Dr. Vigneswaran said of the two surgeries. This statement is backed up in most studies. It’s one of the biggest reasons why pleurectomy/decortication surgery is preferred to extrapleural pneumonectomy.
Survival from P/D is 16‑32 months, based on numerous studies and use of multimodal treatment. Survival from EPP is around 18 months usually. In the SMART study, it was as high as 3‑4 years.
“Surgery has evolved from where it was always pneumonectomy to more and more pleurectomy/decortication,” Dr. Vigneswaran said.
The rise of P/D meant more patients could have surgery. The ability to remove a chunk of tumors without resecting the lung meant better outcomes for older patients.
We can help you connect with Dr. Wigneswaran or another specialist surgeon to find out if surgery is an option. They’ll also tell you which surgery is appropriate for your case. Email our lead patient advocate, registered nurse Karen Ritter, at email@example.com.
Sources & Author
- Extrapleural pneumonectomy (EPP) vs. pleurectomy decortication (P/D). Annals of Translational Medicine. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5497106/. Accessed: 12/07/2020.
- Extrapleural Pneumonectomy versus Pleurectomy/Decortication for Malignant Pleural Mesothelioma. Annals of Surgical Oncology. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/33971174/. Accessed: 05/21/2021.
- A feasibility study evaluating Surgery for Mesothelioma After Radiation Therapy: the “SMART” approach for resectable malignant pleural mesothelioma. Journal of Thoracic Oncology. Retrieved from:
https://www.ncbi.nlm.nih.gov/pubmed/24445595. Accessed: 04/28/2020.
Sources & Author