Surgery for malignant pleural mesothelioma

Abstract

Malignant pleural mesothelioma (MPM) remains a challenging disease from the surgical perspective. Its diffuse nature with involvement of the lung, pericardium, and diaphragm; the inability to reliably obtain negative margins; the significant morbidity and mortality associated with radical resection; and most importantly, the high recurrence rate after surgery, all contribute to the nihilistic attitude with which most clinicians view this disease. Despite major improvements in operative mortality over the last 2 decades, which is now between 2% and 8% at most centers, surgery alone is associated with high rates of local failure. For this reason, adjuvant and neoadjuvant modalities have been integrated into the surgical management of MPM. In most centers today, aggressive therapeutic approaches involve a trimodality regimen including extrapleural pneumonectomy (EPP), radiation therapy, and chemotherapy. The low incidence of MPM (2500-3000 cases per year in the United States) has contributed to the lack of reliable clinical data regarding optimal therapy for this disease. Most surgical series have been single-center retrospective studies that have spanned many years or prospective phase I and II trials that have involved small numbers of patients. To date, there has been no randomized study that has included surgery in the therapeutic regimen. Evidence for the efficacy of surgery has been largely based on comparison of highly selected patients who have undergone resection to unselected historical controls. Comparisons between retrospective studies in MPM are confounded by numerous factors including: