Surgical options in malignant pleural mesothelioma: extrapleural pneumonectomy or pleurectomy/decortication

Two operations have evolved for the surgical treatment of malignant pleural mesothelioma (MPM): extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). The goal of surgery in the multimodality treatment approach is to achieve a macroscopic complete resection, with adjuvant therapies directed at residual microscopic disease. Overall survival reported in a recent multicenter analysis of these two operations supports the use of P/D for early stage MPM provided that a complete resection is feasible; otherwise EPP will confer a survival advantage. For stage II disease, however, EPP demonstrates a possible advantage. The focus in stage III disease should remain on the ability to achieve macroscopic complete resection, rather than N2 disease. Patients with stage IV cancers have better survival if the lung is left in place.