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Journal of Thoracic Disease Mar 2019The extra-pleural pneumonectomy (EPP) is a standardised surgical procedure born for pleural tuberculosis and later used in pleural cancer treatment, especially in... (Review)
Review
The extra-pleural pneumonectomy (EPP) is a standardised surgical procedure born for pleural tuberculosis and later used in pleural cancer treatment, especially in malignant pleural mesothelioma (MPM). This systematic review aimed to focus on the actual overall EPP role in surgical oncology. The literature search was performed from January 1985 to January 2018 In PubMed, Embase, and Cochrane according to PRISMA protocol. The search was restricted to publications in English with the research words "extrapleural pneumonectomy", "malignant pleural mesothelioma", "pleural malignancies". The results were then filtered focusing only on papers with series of patients treated with EPP, for mesothelioma and non-mesothelioma malignancies. The search was restricted to publications in English. We found a 5-year overall survival (OS) ranging from 0 to 78%. The peri-operative mortality and morbidity ranged from 0 to 11.8% and 0 to 82.6%, respectively. The most represented and described post-operative complications reported were ARDS, pericardial tamponade, cardiac herniation, pulmonary embolism, respiratory infections, respiratory failure, atrial arrhythmia, myocardial infarction. In referral centres and selected patients, EPP is a cytoreductive or radical surgical treatment in extended pleural malignancies. Prospective studies are needed to standardise the timing of the procedure in a multimodality treatment program, according to the oncological and functional indications, to keep an acceptable complications rate and post-operative quality of life status.
PubMed: 31019792
DOI: 10.21037/jtd.2019.02.61 -
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 -
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 -
BMJ Open May 2024Extrapleural pneumonectomy (EPP) and extended pleurectomy/decortication (ePD) are surgical cytoreductive techniques aimed at achieving macroscopic resection in malignant... (Review)
Review
INTRODUCTION
Extrapleural pneumonectomy (EPP) and extended pleurectomy/decortication (ePD) are surgical cytoreductive techniques aimed at achieving macroscopic resection in malignant pleural tumours such as pleural mesothelioma, non-mesothelioma pleural malignancies such as thymoma and sarcoma, and rarely for pleural tuberculosis, in a more limited fashion. Despite extensive studies on both surgical techniques and consequences, a significant knowledge gap remains regarding how best to approach the perioperative anaesthesia challenges for EPP and ePD.It is unknown if the risk stratification processes for such surgeries are standardised or what types of functional and dynamic cardiac and pulmonary tests are employed preoperatively to assist in the perioperative risk stratification. Further, it is unknown whether the types of anaesthesia and analgesia techniques employed, and the types of haemodynamic monitoring tools used, impact on outcomes. It is also unknown whether individualised haemodynamic protocols are used to guide the rational use of fluids, vasoactive drugs and inotropes.Finally, there is a dearth of evidence regarding how best to monitor these patients postoperatively or what the most effective enhanced recovery protocols are to best mitigate postoperative complications and accelerate hospital discharge. To increase our knowledge of the perioperative and anaesthetic treatment for patients undergoing EPP/ePD, this scoping review attempts to synthesise the literature and identify these knowledge gaps.
METHODS AND ANALYSIS
This scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Review Protocols methodology. Electronic databases, OVID Medline, EMBASE and the Cochrane Library, will be systematically searched for relevant literature corresponding to EPP or ePD and perioperative or anaesthetic management. Data will be analysed and summarised descriptively and organised according to the three perioperative stages: preoperative, intraoperative and postoperative factors in clinical care.
ETHICS AND DISSEMINATION
Ethics approval was not required. The findings will be disseminated through professional networks, conference presentations and publications in scientific journals.
Topics: Humans; Pneumonectomy; Anesthesia; Pleura; Perioperative Care; Pleural Neoplasms; Postoperative Complications
PubMed: 38760041
DOI: 10.1136/bmjopen-2023-078125 -
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 -
Journal of Clinical Oncology : Official... Apr 2009Malignant pleural mesothelioma (MPM) is a deadly disease that occurs in 2,000 to 3,000 people each year in the United States. Although MPM is an extremely difficult... (Review)
Review
Malignant pleural mesothelioma (MPM) is a deadly disease that occurs in 2,000 to 3,000 people each year in the United States. Although MPM is an extremely difficult disease to treat, with the median overall survival ranging between 9 and 17 months regardless of stage, there has been significant progress over the last few years that has reshaped the clinical landscape. This article will provide a comprehensive discussion of the latest developments in the treatment of MPM. We will provide an update of the major clinical trials that impact mesothelioma treatment in the resectable and unresectable settings, discuss the impact of novel therapeutics, and provide perspective on where the clinical research in mesothelioma is moving. In addition, there are controversial issues, such as the role of extrapleural pneumonectomy, adjuvant radiotherapy, and use of intensity-modulated radiotherapy versus hemithoracic therapy that will also be addressed in this manuscript.
Topics: Humans; Mesothelioma; Pleural Effusion, Malignant
PubMed: 19255316
DOI: 10.1200/JCO.2008.19.8523 -
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 2017Multimodality treatment including macroscopic complete resection (MCR) is currently the most effective therapy for patients with malignant pleural mesothelioma (MPM).... (Review)
Review
Multimodality treatment including macroscopic complete resection (MCR) is currently the most effective therapy for patients with malignant pleural mesothelioma (MPM). However, the allocation to one of the possible combinations has to be discussed individually since various factors influence the decision making process. In the past years, relevant new information about the disease and the outcome of different treatment modalities have been generated, which allows a more individual allocation to the best treatment. For many years extrapleural pneumonectomy (EPP)-the most aggressive procedure to achieve a MCR-was the first choice in combination with adjuvant or neo-adjuvant chemotherapy and radiation therapy for all patients except those with minimal disease. However, mortality and morbidity of an EPP and the fact, that even with the most radical procedure only MCR and not a complete resection can be achieved, led to shift towards pleurectomy/decortication in most of the centers. But also today, EPP is still a valuable option in selected cases and the entire treatment concept requires a nuanced view, which will be discussed in this review.
PubMed: 28706905
DOI: 10.21037/atm.2017.03.88 -
JTCVS Techniques Jun 2020
PubMed: 34317795
DOI: 10.1016/j.xjtc.2020.03.033