Surgery plans a vital role in the care of malignant pleural mesothelioma, researchers from Baylor College of Medicine state, stressing that such operations should be restricted to experienced surgeons with excellent track records. Their perspective aims to complement recently released guidelines by the European Society For Medical Oncology (ESMO).
The ESMO guidelines for malignant pleural mesothelioma treatment, along with guidelines by the Asbestos Diseases Research Institute (ADRI) in Australia and the National Comprehensive Cancer Network (NCCN) in the United States, are intended to cover all aspects of pleural mesothelioma care. But Ori Wald and David J. Sugarbaker of Baylor, in Houston, Texas, suggested that the ESMO guidelines lack clarity on the role of cyto-reductive surgery in pleural mesothelioma.
In a proportion of patients with localized pleural mesothelioma, surgery, in combination with chemotherapy and, sometimes, radiotherapy, may be the best therapeutic option. While the authors agree that the ESMO guidelines correctly highlight the pros and cons of radical surgery in this group of patients, such as good survival but high risk of death, they think these remarks are incomplete.
In their article, “Perspective on malignant pleural mesothelioma diagnosis and treatment“, which recently appeared in the journal Annals of Translational Medicine, the researchers use ADRI and NCCN guidelines, along with other published studies and their own clinical expertise, to clarify the diagnostic procedures, including a correct estimation of disease stage and preceding surgery, and to highlight specific factors that may aid in increasing the proportion of successful operations, and as a consequence, patient survival.
Drs. Wald and Sugarbaker state that an extensive assessment of disease stage needs to be performed before surgery is considered. In addition, they recommend imaging, such as computed tomography (CT) and magnetic resonance imaging (MRI), of the chest to assess the extent of cancer, and positron emission tomography (PET)-CT scan to assess the presence of distant metastases.
Such a lengthy staging procedure might prevent the need to re-classify disease stage, as clinical teams frequently discover a more pronounced disease during surgery. Also, patients with stage III or IV disease tend to have higher rates of recurrent cancer after surgery than stage I-II patients.
The authors agree with ESMO guidelines that surgery in pleural mesothelioma needs to be performed in combination with other treatments, such as chemotherapy, and that clinicians should decide when it is possible to remove the whole tumor.
Two types of surgery exist for the removal of mesothelioma tumors [extrapleural pneumonectomy (EPP) or lung-sparing pleurectomy with decortication (P/D)], and while some guidelines recommend one method over the other, Drs. Wald and Sugarbaker conclude that there is no support for the superiority of either method in the literature.
Much more important is the clinical experience of the surgeon, the doctors conclude. “There is no substitute for a highly experienced surgeon and for a competent multidisciplinary medical team in order to optimize clinical outcomes,” they wrote, echoing ADRI and NCCN recommendations.