Surgical Therapeutic Options

Abstract

We congratulate Neumann et al. on their review article about malignant pleural mesothelioma (MPL) (1). However, the surgical therapeutic options require rectification: For the purposes of palliative treatment, video-assisted thoracoscopic surgery (VATS) with drainage of effusion and talc pleurodesis may be sufficient. The authors presented only the palliative approach of pleurectomy and decortication (P/D), which merely helps to expand the trapped lung. No significant effect on long-term survival has been observed for this intervention. In “extended” P/D or radical pleurectomy (RP), the diaphragm and/or pericardium are resected simultaneously (2, 3). Total visceral and parietal pleurectomy yields maximal cytoreduction. In patients with infiltration of the diaphragm, pericardium, and/or pulmonary parenchyma, these structures can be resected simultaneously. For multimodal therapeutic approaches, larger studies have shown a median survival after extended P/D or RP of 23 to 32 months (3, 4). For stage 1, the median survival is not 22 months, as explained in the article, but actually 23 to 40 months (3). In sum, surgery-related mortality and morbidity have been notably reduced in recent years thanks to extended P/D and RP. It has become possible to offer RP, which is less physically demanding for patients, to more patients, and multimodal therapeutic approaches have improved long-term survival. The prerequisite, however, is that patients be treated in an experienced center with a multidisciplinary expert panel, including certified thoracic surgeons. The risk is that, on the basis of the current article, patients with pleural mesothelioma will be left to their own devices and will possibly not receive effective treatment, including thoracic surgery.