Video-atlas of radical pleurectomy for malignant pleural mesothelioma.

Abstract

Malignant pleural mesothelioma (MPM) is an aggressive malignancy arising from the mesothelial surfaces of the pleura. Macroscopic complete resection (MCR) seems to have the greatest impact on survival in surgery-based multimodality treatment protocols (1). Depending on the surgical preference and intraoperative findings, extrapleural pneumonectomy (EPP) or aggressive radical pleurectomy (RP) or pleurectomy/decortication (P/D) might achieve MCR even at advanced stages or in the presence of higher tumor burden (2). There is a variable definition of RP and P/D in the literature. In our definition, RP is a surgical procedure with complete lung-sparing resection of the visceral and parietal pleura (3). Wedge resections are carried out in the event of deep infiltration of the lung parenchyma. Care is taken to preserve the phrenic nerve, pericardium and diaphragm whenever possible. If necessary, partial or total resection and reconstruction of the diaphragm and pericardium can be carried out. In contrast, the International Association for the Study of Lung Cancer International Staging Committee (IASLC) and the International Mesothelioma Interest Group (IMIG) define P/D as a surgical procedure to remove all macroscopic tumour involving the parietal and visceral pleura. The term “extended” P/D was proposed for additional diaphragmatic or pericardial resection (4). Furthermore, it has been shown that patients undergoing P/D and having incomplete resection (R2) might have comparable survival to patients having MCR with EPP (5). Thus, it is very important to have the ability to perform RP in the management of MPM from a functional and/or oncological point of view. The accompanying video represents an effort to demonstrate the key steps in how to perform RP.