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Extrapleural Pneumonectomy

For mesothelioma treatment, extrapleural pneumonectomy surgery involves involving complete removal of the lung containing the tumor along with both the pleural layer that lines the chest cavity and the pleural layer that covers the lung, most of the diaphragm on the affected side and a part of the nerve that controls the movement of the diaphragm.

Extrapleural Pneumonectomy for Debulking of the Mesothelioma Tumor

When doctors talk about cytoreduction in reference to a malignancy, they are referring to debulking a tumor, which cannot be completely removed. By making the tumor smaller, it enhances the effectiveness of chemotherapy and/or radiation treatments that will be given after the surgery. Extrapleural pneumonectomy is the type of mesothelioma surgery used for cytoreduction. Even though the surgery is extremely complex, survival is possible, but it is dependent on a number of factors.

In a study titled Clinical and pathological features of three-year survivors of malignant pleural mesothelioma following extrapleural pneumonectomy, published online February 8, 2011 in the European Journal of Cardiothoracic Surgery, researchers examined the International Mesothelioma Program Patient Data Registry at Brigham and Women’s Hospital to find all patients who underwent extrapleural pneumonectomy for malignant pleural mesothelioma between January 1, 1988 and May 31, 2007. They identified 636 patients, 117 survived at least 3 years following surgery, including 26 remaining alive and four lost to follow-up.

The researchers observed that among the 3-year survivors, 39 were women, 61had left-sided tumor, and the average age was 56 years. In fact, more of the survivors were at the average age or younger, were women, had a tumor made up of epithelial cells, and/or had normal white blood cell count, hemoglobin, or platelet count before the operation.
The average survival time of the 117 patients who survived for three years or more was 59 months. However, the researchers noted that a significant association between age and survival was found for women. No such association existed for men who underwent extrapleural pneumonectomy.

Based on their findings, the researchers concluded that:

A significant proportion of patients undergoing extrapleural pneumonectomy for pleural mesothelioma experienced extended survival. Although favorable prognostic features were more common, the cohort of 3-year survivors included a substantial number of patients with late-stage disease. The longest survival (median greater than 7 years) was experienced by women under the median age of 56 years.

They also felt that the evidence supported the use of extrapleural pneumonectomy for debulking a large portion of the tumor as part of a multimodality therapy, meaning using more than one treatment, to extend survival for malignant pleural mesothelioma.

Extrapleural Pneumonectomy to Relieve Mesothelioma Symptoms

A major symptom associated with pleural mesothelioma is what is known as dyspnea, or shortness of breath. A form of dyspnea, called orthopnea, which is difficulty breathing unless sitting/standing upright, can also be a symptom. Extrapleural pneumonectomy has been used to relieve, or palliate, these symptoms. However, a new study questions the benefit of such extreme surgery for symptom improvement given its high mortality rate and rate of disease recurrence.

The study titled Extrapleural pneumonectomy or supportive care: treatment of malignant pleural mesothelioma, published online March 8, 2011 in Interactive CardioVascular and Thoracic Surgery, researchers looked for studies comparing extrapleural pneumonectomy and other forms of treatment for symptom remediation. They found 14 they felt provided the best evidence to answer the question of whether or not extrapleural pneumonectomy was the superior form of treatment.

Of the 14 studies, 10 evaluated the role of extrapleural pneumonectomy. The average survival time of these patients was 13 months with a 5.7 percent mortality rate between the time after surgery and the conclusion of hospital stay, and 9.1 percent mortality rate after 30 days. There was a high rate of disease including atrial fibrillation, pus buildup in the space between the lung and the chest wall and irregular heartbeat in the tissue above the ventricles. The disease recurred in 73 percent of the patients after an average period of 10 months.

Three months after surgery, symptoms had improved in 68 percent of the patients.

Two studies examined outcomes after chemotherapy. The average survival time was 13 months and symptoms improved in 50 percent of patients. The average time until the disease progressed was 7.2 months. The conditions that resulted from this treatment included an abnormally low level of white blood cells, anemia, and an abnormally low level of platelets.

The final two studies talked about symptom remediation by methods other than extrapleural pneumonectomy. The average survival for patients in these studies was seven months and symptoms were improved in 25 percent one year after treatment. The 30-day mortality rate was 7.8 percent and complications included prolonged air leak and pus buildup in the space between the lung and the chest wall.

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