Is EPP Superior to Supportive Care in the Treatment of Malignant Pleural Mesothelioma?

As published in the Annals of Cardiothoracic Surgery February 2011 issue.

The question of whether extrapleural pneumonectomy (EPP) is superior to supportive care, in terms of morbidity, symptom control and survival, in the treatment of patients with malignant pleural mesothelioma (MPM) is examined by reviewing 14 papers best demonstrating the evidence to answer this question. After relevant outcomes and results were tabulated, this study concludes that EPP confers no advantage to chemotherapy and palliative treatment in terms of survival and symptom improvement.

According to the study, the median survival was 13 months, 5.7% perioperative mortality rate and 9.1% 30-day mortality rate. There was a high morbidity rate of 37% during surgery due to the following factors: atrial fibrillation, empyema and supraventricular arrhythmias. Disease recurred in 73% of patients at a median time of 10 months. Median hospital stay was 13 days and intensive care unit stay was 1.5 days. At three months post-surgery, improvement in symptoms was achieved in 68% of patients, with significant advantages observed in patients with epithelial MPM compared to non-epithelial MPM.

Management of MPM may include the use of chemotherapy or surgery with palliative intent. However when the EPP is used with curative intent, studies show that is likely to fall short of expectations. The clinical bottom line to this study is that EPP is a highly morbid operation with high perioperative mortality and recurrence rate. Although a number of retrospective studies have shown a small benefit in survival with EPP, there is consensual agreement that even in subgroups with the best prognostic indicators, such as epithelial histology or negative lymph node metastasis, EPP still results in high complication rates with minimal symptomatic improvement. 

The MARS trial, which clearly demonstrates the detrimental effects of conducting EPP surgery compared to conservative management, is especially significant. This study also reported that lung-sparing radical decoration surgery tends to produce higher median survival rates compared to palliative surgery.

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