Treatment options for malignant mesothelioma

Surgical procedures

Extrapleural pneumonectomy

Extrapleural pneumonectomy (EPP) is a more aggressive operation than pleurectomy and is performed to remove all visible evidence of tumor. The chest wall is opened at the back and side of the chest, with the incision extending down towards the diaphragm. The 6th rib is removed. Alternatively, the surgeon may use an abdominal approach in addition to the chest opening. Both layers of the pleura, the lung on the affected side, the pericardium and diaphragm are removed. Special grafting materials are used to patch the pericardium (to protect the heart) and diaphragm (to prevent abdominal organs from migrating into the chest). Chest tubes (left in place for some days) are inserted between the ribs to drain blood and fluids, and to manage air leaks from the lungs. Blood transfusions may be required.

In the past, up to 31% of patients died during or just after EPP; nowadays this figure is closer to 5-10%. Serious complications occur in as many as 25% of patients with EPP and include:

• Bronchopleural fistula (development of an abnormal connection between the breathing tubes and the pleura, allowing air to leak out from the lungs).
• Empyema (collection of pus in the pleural space).
• Vocal cord paralysis.
• Chylothorax (collection of fatty lymphatic fluid in the chest).
• Irregular heart rhythms (which may affect 25-40% of patients).
• Breathing difficulties.
• Heart attack.
• Heart failure.
• Gastrointestinal (stomach & intestinal) problems.

The median survival after EPP for malignant mesothelioma ranges from 4-21 months, and 10-38% of patients survive to 2 years. As with pleurectomy, these wide ranges occur because different research groups use various treatment combinations (surgery performed with or without radiation therapy or chemotherapy) and select their patients differently. Also, survival seems to vary with tumor type (better with epithelial type). Patients should seek information about the experience and results at the facility where they are being treated. Because of the radical nature of EPP and the high rate of post-operative deaths, it should only be performed in centers where at least 10 such procedures are done each year. Patients should be carefully selected and should be less than 70 years of age. Tumor recurrence more usually occurs as distant metastases.