The Rationale for Multimodality Therapy Incorporating Lung-Sparing Surgery

Although historically, extrapleural pneumonectomy (EPP) was the preferred surgical approach to the management of malignant pleural mesothelioma (MPM), physician and patient preferences have contributed to an increased number of lung-sparing pleurectomy/decortication (P/D) surgeries now being performed. Given the growing body of research and when patients face the option of a less extensive surgery that is equally or more effective than the EPP, has caused this dramatic impact in thoracic surgeon practice patterns.

The P/D involves resection of the pleura but leaves the uninvolved lung intact. It is already associated with less morbidity during surgery and increased life-expectancy. The EPP has been well studied in the multimodality paradigm and has shown that many patients are unable to tolerate post-operative radiation and/or chemotherapy. Given these challenges, many investigators are exploring how best to incorporate P/D into a multimodality treatment program.

This study examined the value of EPP versus P/D in a retrospective analysis of 667 patients. Early data suggests that since adjuvant therapy is more tolerable in P/D patients, multimodality therapy with P/D is associated with improved survival. Treating MPM patients with intact lungs with pleural intensity modulated radiation (IMRT) is feasible and safe and is associated with encouraging survival rates in this retrospective cohort.

In conclusion, MPM patients clearly benefit from a multimodality approach, but the optimal combination of surgery, chemo and radiation merits more investigation. As more patients undergo P/D surgery instead, the EPP-centric multimodality paradigm is shifting to integrate this trend. Researchers are also currently evaluating a novel paradigm of preoperative chemo followed by P/D and pleural IMRT in a prospective phase II trial.