In the report published on 6th December, 2018, the researchers from the University Hospitals KU Leuven, Belgium revealed the surgical importance of extrapleural pneumonectomy (EPP) in improving the survival rate of malignant pleural mesothelioma (MPM) patients as the study showed 33.2 months median survival time, and 5 year survival time for 24.2% patients who underwent the complete procedure.

Belgian doctors conducted thorough research on 97 selected patients suffering from malignant pleural mesothelioma, to characterize the significance of extrapleural pneumonectomy (EPP) surgery on the survival rate of patients. Even though EPP has not been a popular surgical procedure among many of the American and European surgeons, the Belgian doctors have certainly leaped and shown the successful outcomes of using this method.

Among 197 patients registered between 2003 to 2014, the study started with 97 patients who qualified to undergo EPP in a multidisciplinary treatment to cure mesothelioma.
Out of these 97 patients, doctors performed surgery on 76 patients. Fifty-six patients underwent extrapleural pneumonectomy, and 20 underwent exploratory thoracotomy.

Among these 56 patients who received EPP treatment, three survived for ten years or more, and four patients have hit the five years mark, and are showing sparkling chances of reaching the 10-year mark.

Authors of the report discussed the significant positive results achieved with the use of this controversial surgical procedure to remove the malignant tumor, saying

"CMT with EPP for MPM is feasible, with an acceptable surgical mortality rate, and results in a 5-year survival rate of 24%."

Here, CMT stands for Combined Modality Treatment done of treating malignant pleural mesothelioma.

Debate Regarding the Superiority Between P/D and EPP

After the publication of MARS (Mesothelioma and Radical Surgery) trials in the year 2011, the number of EPP surgeries performed significantly decreased, or in some areas stopped in the US and Europe.

This statistical, that was conducted on the patients of 12 UK hospitals, specifically emphasized on the prospects of EPP surgery. It concluded that EPP is not worth performing as it is associated with a high morbidity rate, high mortality rate, the low overall quality of life, and no benefits for survival rate.

The study interpreted from the data obtained that,

"The evidence from MARS, in the context of external evidence from observational studies, suggests that the net effect of EPP is to shorten survival without a gain in quality of life."

For the treatment of malignant pleural mesothelioma generally, surgeons plan on performing cytoreductive surgery rather than opting for radical procedures.

Recent research has shown a significant improvement in the survival rate after performing a combination of cytoreductive surgery and Hyperthermic intraperitoneal chemotherapy (HIPEC).

In the lane of radical surgeries to treat malignant pleural mesothelioma, in spite of doing EPP surgery, many surgeons from the USA and Europe prefer performing Pleurectomy/decortication (P/D).

This method is preferred because P/D is a less aggressive procedure, and has comparatively less morbidity/ mortality rate.

Still, there is a lot of debate, regarding which method is possible less damaging and comparatively more beneficial for the patient.

Low Mortality Rate Recorded in the Current Study

The main concern of the scientific community with EPP surgery is the high mortality/ morbidity rate of the patients after surgery. Shockingly, in this Belgian research, 56 patients who underwent EPP research none of them died in the first month after surgery, and two patients died within 90 days.

According to the data presented by the Belgian National Cancer Registry, in male mesothelioma patients, the 1-year survival rate is 46.3% whereas, in female mesothelioma patients, it is 50.7%. The 5-year survival rate is shallow, as it 4.9% for male patients and 8.3% for female patients.

Considering the data available, the current research done by the Belgian doctors have opened the doors for increasing the survival rate to a much higher level.

Eliminating the Chances of Concerned Post Surgical Complications

The Belgian research team has thoroughly outlined the most common medical complication (atrial fibrillation) and surgical complications including bronchopleural fistula, diaphragmatic patch dehiscence, empyema, and haemothorax, that are of concern using EPP as a surgical procedure to treat MPM.

In this regard, the researchers have emphasized the importance of using the comprehensive protocol in a well equipped, and exceptionally sterilized environment by highly qualified and experienced surgeons. As in this study, the occurrence of these commonly concerned medical and surgical complications was nominal. According to the results of the surgical experiment, the authors have written,

"In our study, major surgical complications such as rebleeding, empyema and chylothorax were seen in only 5 patients (8.9%)."

Similarly, the incidence of other complications was also very low,

"We did not observe bronchopleural fistula, and only 1 patient (1.8%) developed a postoperative empyema. This finding can be explained by our surgical protocol of performing an extensive washout and using an intercostal muscle flap to protect the bronchial stump."

Likewise, in another study published in the Journal of Thoracic and Cardiovascular Surgery in 2004 by the American scientists, out of 328 patients who underwent EPP bronchopleural fistula was recorded in only two patients (0.6%).

Concluding the discussion along with their experimental proof in hand, the researchers said that,

"EPP should be limited to experienced centers within the boundaries of well-controlled studies or clearly defined clinical protocols performed by a multidisciplinary oncology team."

Highly Optimized Patient Selection is Critical for the Success of the Surgery

Extrapleural pneumonectomy is scientifically among the most aggressive procedures to treat cancers, as it involves the removal of the complete removal of the lung, it's lining (pleura), pericardium (lining of the heart), and diaphragm to cut off a significant portion of affected parts.

Owning to the significant complications attached to the EPP, and its aggressive approach towards eradicating the cancerous tissue, a thoughtful and highly optimized selection of patients is critical. As the researchers have concluded,

"Careful patient selection is of the highest importance because only half of the patients are able to complete CMT."

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