Mesothelioma Cancer Palliative Surgical Procedures

Palliative Surgical Procedures

1. Parietal Pleurectomy

As the disease progresses, many patients are developing malignant pleural effusions. A pleural effusion method is to eliminate the parietal pleura. This procedure is performed in the presence of minimal disease in the pleura to remove pleural effusion and encourage pleural adhesion to the chest wall. Generally, parietal pleurectomy is a partial removal of parietal and/or visceral pleura for diagnostic or palliative purposes but leaving gross tumor behind. 

It is a palliative procedure and is less extensive than the MCR. For the procedure to be effective, the lung should be able to completely expand following the removal of the pleural effusion to fill the chest cavity. This is often performed using a video-assisted thoracoscopic approach or small thoracotomy. The procedure provides symptomatic relief in patients with pleural effusion.

2. Pleurodesis/PleurX Catheter

For patients who have advanced diseases or those that cannot tolerate surgery, there are less invasive procedures that can be performed for symptomatic relief. Pleurodesis is a less aggressive form of treating pleural effusion. The objective is to eliminate the pleural space between the two distinct plaudits where the accumulation of liquid can occur by instilling a caustic agent which causes scars. The most commonly used agent is currently a sterile talc powder. To ensure that the talc crying is successfully operating, the lung must re-examine and fill the trunk to allow the adhesion of the pleura.

In cases where there is persistent pleural effusion despite multiple interventions, or the lung will not expand to fill the chest cavity, an indwelling cuffed tunneled catheter can be placed. The procedure can be carried out under local anesthesia for patients who are too sick to tolerate general anesthesia. After the procedure, patients can periodically fix the catheter to a vacuum cartridge and drain the liquid to help relieve their symptoms.

3. Outcomes

Despite several surgical options, no current consensus exists on which procedure offers the best long-term survival. Each surgical option has its own postoperative complications which must be taken into account (Batirel et al. 2016). Complications common to MCR procedures and resections include arrhythmia (atrial fibrillation, supraventricular tachycardia), bleeding requiring prolonged reoperation, and ventilation. 

For the EPP, current complications are bronchopleural fistula and chylothorax and have considerably increased morbidity and mortality. Pleurectomy and decortication complications are prolonged air leak and mucus plugging with atelic- tasis. A focused systematic review on tri-modality therapy involving neoadjuvant or adjuvant chemotherapy, EPP, and adjuvant radiotherapy reported a perioperative mortality rate of 0–12.5%, a morbidity rate of 50–83%, and a median overall survival of 12.8–46.9 months (Cao et al. 2012).

Overall median survival favors pleurectomy and decortication over EPP with ranges from 12 to 23 months for EPP and 19 to 32 months for pleurectomy and decortication (Flores et al. 2008; Taioli et al. 2015; Kostron et al. 2017). Quality of life is generally better for patients undergoing PD compared to EPP, for an extended period following surgery (Ploenes et al. 2013). Given the need for multimodality therapy and the aggressive nature of MPM, quality of life outcomes should be strongly considered when recommending a type of surgery (Vigneswaran et al. 2017).

4. Multimodality Treatment

Surgery is not expected to achieve a complete resection without any residual dis- ease. Therefore, chemotherapy and/or radiotherapy are added as part of multimodality treatment, either in the neoadjuvant or adjuvant environment. Currently, the chemotherapy regime with Cisplatin-Perxed is first-line therapy. Bevacizumab in combination with Cisplatin-Petrexed can provide an additional 2.7-month benefit in selected patients (WU and Dog 2017). 

Radiotherapy using intensity-moderated radiotherapy (IMRT) has been used for pain palliation, for the reduction of local metastasis risk in intervention sites, or as part of a multimodality approach.IMPRINT and SMART trials looked at radiation therapy with pleurectomy/decortication and EPP, respectively, and found that IMRT is a safe and feasible option (Rimner et al. 2016). 

There are numerous ongoing studies that will shed light on the best treatment combination modality. The current standard of care for this deadly disease remains suboptimal which has prompted researchers to explore innovative treatment alternatives. Immunotherapy is an emerging therapeutic modality that takes advantage of the power of the human immune system. 

The blocking of the immune control point, immunotoxins therapy, cancer vaccines, oncolytic viral therapy, and adoptive cell therapy is currently being evaluated in clinical trials. Although some dramatic responses have been observed with these approaches, there are many limitations that remain and must be overcome to improve the effectiveness of these new therapies (Dozier et al. 2017).

Source

Mary Hesdorffer, Gleneara E. Bates-Pappas - Caring for Patients with Mesothelioma_ Principles and Guidelines-Springer International Publishing (2019)

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