Types of surgery post-neoadjuvant chemotherapy for pleural mesothelioma

ABSTRACT

Introduction: The surgical arm of the Mesothelioma and Radical Surgery (MARS) trial involved a multimodal approach, with combined therapy consisting of chemotherapy, complete gross resection, and radiation therapy. However, the MARS trial did not compare surgery with chemotherapy, and the survival and quality of life outcomes of this trial’s surgical arm were inferior to those of the non-surgical arm. Methods for achieving complete gross resection (macroscopic complete response [MCR]) include extrapleural pneumonectomy (EPP), wherein the pleura, lung, diaphragm, and pericardium are removed en bloc, and pleurectomy/decortication (P/D), wherein the affected lung is preserved. Nonetheless, the most effective therapy remains unclear.

Areas covered: Here, surgery post-neoadjuvant chemotherapy for malignant pleural mesothelioma with either EPP or P/D has been discussed, along with trimodal and bimodal therapies.

Expert opinion: With the development of post-P/D radiation therapy, it is currently possible to truly compare EPP with P/D. Moreover, R0 resection cannot be achieved with either EPP or P/D; thus, both must incorporate debulking, although the two procedures are largely incompatible. Therefore, there is a need to rebuild the status of surgery as a multimodal therapy.

KEYWORDS:

• Bimodality
• cytoreduction
• extrapleural pneumonectomy
• macroscopic complete resection
• malignant pleural mesothelioma
• nivolumab
• pleurectomy/decortication
• trimodality

Article highlights

• There exist numerous controversial issues concerning multimodal therapy for MPM.

• Identifying predictors for selecting the type of surgery is critical but not easy.

• R0 resection cannot be achieved with either EPP or P/D.

• EPP and P/D must incorporate debulking, although both procedures are incompatible.

• There is a need to rebuild the status of surgery as a multimodal therapy.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded