Editorial Comment: Lung-sparing total pleurectomy: the surgical option of choice in malignant pleural mesothelioma?

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The incidence of malignant pleural mesothelioma (MPM) in Western Europe is increasing significantly [1]. Increased patient awareness of potential therapy and results from North American centres have stimulated specialist European surgical centres to expand their programs. There has been a shift in specialist surgical opinion away from extrapleural pneumonectomy (EPP) towards lung-sparing surgery in MPM. This may be attributed to an increasing age at presentation with consequent increasing comorbidity, particularly COPD. There is also an increasing appreciation that lung-sparing surgery can prolong survival from MPM. This finding is confirmed by Bolukbas et al .[ 2] in this issue, who report 28% 5-year survival in 42 patients with IMIG Stage III MPM. In their series, survival was even greater (median survival 38 months) in those who underwent a complete resection. Unfortunately, macroscopic complete resection was not achieved in 16 of the 42 patients and one wonders whether EPP may have been preferable in these cases. These authors highlight other important prognostic factors, particularly tumour infiltration of previous diagnostic biopsy sites. While also noted by the Boston group [3], this finding may in itself be a surrogate marker for increased tumour volume, thus leading to incomplete R2 resection, or for unfavourable tumour biology. The clinical implication of this is that core biopsy of suspicious biopsy sites should be performed prior to radical surgery. Positive results could then prompt induction chemotherapy to exclude those who may progress inexorably despite therapy. The time interval between diagnosis and major surgery is not clear in the Wiesbaden experience, but this should be kept as short as possible. Apart from involvement of previous incisions and completeness of excision, Bolukbas did not identify nodal status or cell type as significant prognostic factors. These findings do not correlate with the largest series of survival data for mesothelioma surgery reported by the IASLC staging group [4] and probably reflect the small sample. It is imperative that radical surgery should only be considered in patients whose prognosis would be better than with non-surgical treatment. Comparable data are limited but a Nordic study has reported survival from chemotherapy alone in early-stage disease of 22 months [5]. In the IASLC database, postoperative survival was inferior to this in Stages III and IV disease and in non-epithelioid cell types. The inference is that surgery with life prolongation as its aim should be limited to those patients with epithelioid MPM without nodal metastases, particularly in the upper mediastinum. This area is proposed to represent a later stage of MPM based on a ‘gravitational hypothesis’ in which the disease is suggested to progress from the base to the apex of the hemithorax. The poorer prognosis of paratracheal nodal disease suggested from several series [3, 6] promotes the use of mediastinoscopy in patient selection for radical surgery. As alluded to above, there is increasing enthusiasm for lungsparing radical surgery over EPP. The reduced risk of pneumonectomy avoidance may be as high as 40% [7] together with the potential for preserved respiratory function. The recent under