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Annals of Translational Medicine Jun 2017Pleurectomy and decortication (P/D) improve survival and quality of life in selected patients with malignant pleural mesothelioma. The operative procedure was not...
Pleurectomy and decortication (P/D) improve survival and quality of life in selected patients with malignant pleural mesothelioma. The operative procedure was not standardized until recently. The goal of the operation is to perform a macroscopic complete resection of the tumor. This often involves resection of the parietal and visceral pleura and invariably a partial or complete resection and prosthetic reconstruction of ipsilateral hemidiaphragm. We describe our operative planning and technique as well as outcomes of P/D reported in current literature.
PubMed: 28706914
DOI: 10.21037/atm.2017.04.03 -
BMJ Open Sep 2020Mesothelioma remains a lethal cancer. To date, systemic therapy with pemetrexed and a platinum drug remains the only licensed standard of care. As the median survival...
Mesothelioma and Radical Surgery 2 (MARS 2): protocol for a multicentre randomised trial comparing (extended) pleurectomy decortication versus no (extended) pleurectomy decortication for patients with malignant pleural mesothelioma.
INTRODUCTION
Mesothelioma remains a lethal cancer. To date, systemic therapy with pemetrexed and a platinum drug remains the only licensed standard of care. As the median survival for patients with mesothelioma is 12.1 months, surgery is an important consideration to improve survival and/or quality of life. Currently, only two surgical trials have been performed which found that neither extensive (extra-pleural pneumonectomy) or limited (partial pleurectomy) surgery improved survival (although there was some evidence of improved quality of life). Therefore, clinicians are now looking to evaluate pleurectomy decortication, the only radical treatment option left.
METHODS AND ANALYSIS
The MARS 2 study is a UK multicentre open parallel group randomised controlled trial comparing the effectiveness and cost-effectiveness of surgery-(extended) pleurectomy decortication-versus no surgery for the treatment of pleural mesothelioma. The study will test the hypothesis that surgery and chemotherapy is superior to chemotherapy alone with respect to overall survival. Secondary outcomes include health-related quality of life, progression-free survival, measures of safety (adverse events) and resource use to 2 years. The QuinteT Recruitment Intervention is integrated into the trial to optimise recruitment.
ETHICS AND DISSEMINATION
Research ethics approval was granted by London - Camberwell St. Giles Research Ethics Committee (reference 13/LO/1481) on 7 November 2013. We will submit the results for publication in a peer-reviewed journal.
TRIAL REGISTRATION NUMBERS
ISRCTN-ISRCTN44351742 and ClinicalTrials.gov-NCT02040272.
Topics: Humans; London; Lung Neoplasms; Mesothelioma; Mesothelioma, Malignant; Multicenter Studies as Topic; Pleural Neoplasms; Quality of Life; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 32873681
DOI: 10.1136/bmjopen-2020-038892 -
Annals of the Royal College of Surgeons... Apr 2022Thoracic endometriosis syndrome is an under-recognised manifestation of endometriosis and includes catamenial pneumothorax, catamenial haemothorax, catamenial...
Thoracic endometriosis syndrome is an under-recognised manifestation of endometriosis and includes catamenial pneumothorax, catamenial haemothorax, catamenial haemoptysis and pulmonary nodules. Catamenial pneumothorax presents as recurrent spontaneous pneumothorax with a temporal relationship to the onset of menses, affecting mostly the right lung. A 48-year-old woman presented with an eight-year history of right-sided catamenial pneumothorax, during which time she had three episodes of pneumothorax. Serial chest imaging revealed an enlarging mass overlying the right hemi-diaphragm. She was referred to our trust where she underwent video-assisted thoracoscopic surgery for right pleurectomy. Intraoperatively, defects were found in the right hemidiaphragm, through which parts of the liver had herniated. We describe the presenting features and management of catamenial pneumothorax.
Topics: Diaphragm; Endometriosis; Female; Humans; Middle Aged; Pneumothorax; Thoracic Surgery, Video-Assisted
PubMed: 34825583
DOI: 10.1308/rcsann.2021.0164 -
Turk Gogus Kalp Damar Cerrahisi Dergisi Oct 2021Minimally invasive repair of pectus excavatum (Nuss) operation is the current choice of surgical treatment for pectus excavatum deformities. Technical pitfalls arise in...
Minimally invasive repair of pectus excavatum (Nuss) operation is the current choice of surgical treatment for pectus excavatum deformities. Technical pitfalls arise in patients with previous thoracic and/or cardiac surgical interventions, due to severe intrathoracic fibrous adhesions. Herein, we describe an original modification technique in a patient with bilateral apical wedge resection and total pleurectomy due to recurrent spontaneous pneumothorax episodes within the past two years. Correction was performed by opening the pleura bilaterally and retrosternal release with digital palpation via a subxiphoid incision, to help to guide the introducer and the pectus bar, without a videothoracoscopic visualization.
PubMed: 35096458
DOI: 10.5606/tgkdc.dergisi.2021.21092 -
Translational Lung Cancer Research Oct 2018The optimal treatment of malignant pleural mesothelioma (MPM) has not yet been established and is still under investigation. Surgery is one of the pillars in the... (Review)
Review
The optimal treatment of malignant pleural mesothelioma (MPM) has not yet been established and is still under investigation. Surgery is one of the pillars in the multimodality approach with the purpose of removing as much as visible tumor as possible and to relieve symptoms. To date, two major surgical procedures are available for removal or debulking of MPM that is considered to be resectable: [extended (e)] pleurectomy/decortication (P/D) and extrapleural pneumonectomy (EPP). Historically, EPP was regarded as the only way to achieve a macroscopic complete resection. However, in the last years, there is a shift in literature towards (e)P/D as the preferred surgical procedure whenever possible as several retrospective studies and meta-analyses showed a similar or lower long-term survival and higher perioperative mortality and postoperative morbidity in patients who been treated with EPP. On the other hand, no randomized-controlled trials regarding surgical treatment with (e)P/D or EPP exist and therefore level A evidence favoring one surgical procedure is lacking. In this review we provide a nuanced and well-considered answer to the question whether EPP is still indicated in the surgical treatment of MPM.
PubMed: 30450293
DOI: 10.21037/tlcr.2018.07.07 -
Thoracic Surgery Clinics Feb 2018Pleural metastasis is a common occurrence in up to 30% of patients with metastatic cancer. When lung entrapment and loculation of fluid occur, treatment is more... (Review)
Review
Pleural metastasis is a common occurrence in up to 30% of patients with metastatic cancer. When lung entrapment and loculation of fluid occur, treatment is more difficult and we have named this condition "oncothorax." The malignant adhesions that entrap the lung in an oncothorax are not typically amenable to surgical decortication. The standard approach for managing these patients is to place an indwelling catheter. Other options may include pleurectomy and decortication, intrapleural hyperthermic chemoperfusion, and intrapleural photodynamic therapy. However, these procedures should be provided selectively depending on patient performance status, extent of metastatic disease, and level of experience.
Topics: Antineoplastic Agents; Catheters, Indwelling; Drainage; Humans; Hyperthermia, Induced; Perfusion; Photochemotherapy; Pleural Neoplasms; Thoracic Surgical Procedures
PubMed: 29150040
DOI: 10.1016/j.thorsurg.2017.08.009 -
Journal of Thoracic Oncology : Official... Nov 2018Surgical intervention plays an important role in the diagnosis, staging, and treatment of malignant pleural mesothelioma (MPM) and can be applied with curative or... (Review)
Review
Surgical intervention plays an important role in the diagnosis, staging, and treatment of malignant pleural mesothelioma (MPM) and can be applied with curative or palliative intent. The overall aim of surgery should be, as in any oncologic surgery, the macroscopic complete resection (MCR) of the tumor. Most importantly, the majority of patients with the diagnosis of MPM should be appropriately staged and initially evaluated in a multidisciplinary setting, including medical oncology, radiation oncology, and surgery after histologic diagnosis. Surgical staging, including determination of the histologic subtype and lymph node status, as well as clinical staging with positron-emission tomography-computer tomography scan and determination of cardiopulmonary reserve are crucial. Herein, we summarize the role of surgical resection, specifically macroscopic complete resection, performed as extrapleural pneumonectomy or extended pleurectomy/decortication in multimodality treatment settings and advocate for optimal patient selection for one or the other procedure. In addition, the roles of surgery in diagnosis of MPM and in palliative care are discussed.
Topics: Humans; Lung Neoplasms; Mesothelioma; Mesothelioma, Malignant; Pleural Neoplasms; Survival Analysis
PubMed: 30121394
DOI: 10.1016/j.jtho.2018.08.001 -
Annals of Translational Medicine Jun 2017Surgical techniques for treatment of malignant pleural mesothelioma (MPM) have improved over the decades. The main surgical principle was accepted as macroscopic... (Review)
Review
Surgical techniques for treatment of malignant pleural mesothelioma (MPM) have improved over the decades. The main surgical principle was accepted as macroscopic complete resection. This principle was achieved with extrapleural pneumonectomy (EPP) and extended pleurectomy/decortication (P/D). Mortality and morbidity are higher following EPP with supraventricular arrhythmias, pulmonary embolism, bronchopleural fistula and pulmonary failure being the most common, while prolonged air leak is frequent following P/D. Completion of multimodality treatment was also shown to be a prognostic factor. Many different neoadjuvant and adjuvant protocols were applied with limited effect on prognosis. While locoregional recurrence is more common following P/D, EPP patients typically recur in contralateral hemithorax and abdomen. Hemithoracic radiation following EPP was the only effective technique shown to decrease locoregional recurrence. However, neither surgical technique (EPP P/D), nor types of multimodality treatment protocols were found to be prognostic in MPM. Epithelioid histology, metastasis to extrapleural lymph nodes and completion of multimodality treatment were prognostic in most of the series. In conclusion, based on the current evidence, the choice of a less morbid and mortal procedure (P/D) seems to be the logical choice in the treatment of MPM.
PubMed: 28706900
DOI: 10.21037/atm.2017.03.82 -
Translational Lung Cancer Research Oct 2018Extended pleurectomy/decortication (EPD) has been formally defined but there remain technical areas of debate between practitioners. This is partly attributable to the... (Review)
Review
Extended pleurectomy/decortication (EPD) has been formally defined but there remain technical areas of debate between practitioners. This is partly attributable to the relative rarity of this operation which is largely confined to a small number of specialist centres. Nevertheless, there is a widespread acceptance that extended pleurectomy/decortication (P/D) is a realistic and favourable alternative to extrapleural pneumonectomy. There may, however, remain a small number of clinical cases where this more extensive operation may be indicated. Preservation of the lung has widened the selection criteria for this form of radical mesothelioma surgery but there remain important factors to consider when offering extended P/D. In many patients with poorer prognostic factors the less radical operation of video assisted partial pleurectomy may be preferable. However, a randomized trial showed no survival benefit for this operation over simple talc pleurodesis. The future for P/D may also lie in the outcome of the MARS2 randomized controlled trial which will report in the next few years. Meanwhile there is a clinical and ethical dilemma when asked to perform this operation outside of the context of a clinical trial in the face of the lack of high grade evidence. The role of P/D is in one respect expanding but this may be short lived pending the findings of its assessment against non-surgical treatment.
PubMed: 30450294
DOI: 10.21037/tlcr.2018.06.07 -
Annals of Oncology : Official Journal... Aug 2018Malignant pleural mesothelioma (MPM) is a rare malignancy with some unique characteristics. Tumor biology is aggressive and prognosis is poor. Despite more knowledge on... (Review)
Review
Malignant pleural mesothelioma (MPM) is a rare malignancy with some unique characteristics. Tumor biology is aggressive and prognosis is poor. Despite more knowledge on histology, tumor biology and staging, there is still a relevant discrepancy between clinical and pathologic staging resulting in difficult prediction of prognosis and treatment outcome, making treatment allocation more challenging than in most other malignancies. After years of nihilism in the late 80s, a period of activism started evaluating different treatment protocols combined with research driven mainly by academic centers; at the time, selection was based on histology and stage only. This period was important to gain knowledge about the disease. However, the interpretation of data was difficult since selection criteria and definitions varied substantially. Not surprisingly, until now there is no common agreement on best treatment even among specialists. Hence, a review of our current concepts is indicated and personalized treatment should become applicable in the future. Surgery was and still is an issue of debate. In principle, surgery is an effective approach as it allows macroscopic complete elimination of a tumor, which is relatively resistant to medical treatment. It helps to set the clock back and other therapies that have also just a limited effect can be applied sequentially before or after surgery. Furthermore, to date best long-term outcome is reported from surgical series in combination with other modalities. However, part of the community considers surgery associated with too high morbidity and mortality when balanced to the limited life expectancy. This criticism is understandable, since poor results after surgery are reported. The present article will review the indication for surgery and discuss the different procedures available for macroscopic complete resection-such as lung-preserving (extended) pleurectomy/decortication as well as extrapleural pneumonectomy to illustrate that 'The surgeon is still there!'
Topics: Chemotherapy, Adjuvant; Clinical Trials as Topic; Disease-Free Survival; Humans; Lung; Lung Neoplasms; Mesothelioma; Mesothelioma, Malignant; Neoadjuvant Therapy; Neoplasm Staging; Organ Sparing Treatments; Pleura; Pleural Neoplasms; Pneumonectomy; Prognosis; Radiotherapy, Adjuvant; Treatment Outcome
PubMed: 29905765
DOI: 10.1093/annonc/mdy195