**2.5 Extracorporeal life support (ECLS) for life-threatening complications in MPM's surgery: is it worthwhile?**

In thoracic surgery, the use of ECLS in the postoperative period is augmented in the last decades [53]. Up to now, the unique absolute contraindication to extracorporeal membrane oxygenation (ECMO) is a pre-existing state incompatible with healing, such as an end-stage tumor [54]. Literature provides only a few reports on ECLS as a bridge to support oncological patients affected by complications of their illness [55], its therapy [56, 57] or cardiac arrest [58]. MPM is a locally aggressive tumor, with a very poor prognosis. The multimodality therapies including surgery offered to selected cases (early stages with epithelial histology) are often characterized by major and/or minor perioperative morbidities [13]. According to Burt et al., the EPP is burdened by a significantly higher rate of acute distress respiratory syndrome (ARDS) (8.4 vs. 0.8%) and 30-day mortality (10.5 vs. 3.1%), compared to the PD [52, 59]. Anyhow, in the case of perioperative complications after surgery for MPM the employment of ECLS represents an ethical dilemma due to the fatal nature of this malignancy.

Fica and collaborators mentioned the use of a single-site veno-venous ECMO to support ventilation in an early post-pneumonectomy broncho-pleural fistula [57], while Bellini and collaborators successfully used the veno-arterial (V-A) ECMO as cardiac support in two MPM patients (66%), conversely, the only case (33%) of V-A ECMO implanted primarily for respiratory support in pneumonia-associated ARDS of the residual lung had a negative outcome [60]. Similar results were reported in the literature; according to Gow and collaborators, patients with a better pulmonary reserve and cardiac indication for ECLS are the better oncological candidates for ECMO [61].

The disease process itself and/or the employed treatments lead patients with thoracic cancer to have less pulmonary reserve compared to adults generally demanding ECLS. Secondary infections and bleeding are the major problems for the use of ECLS for oncological patients [61], both potentially life-threatening. In this scenario, on one hand, we have potentially reversible complications not responsive to conventional therapies, while on the other hand frail and immunosuppressed patients with poor prognosis and at risk to develop life-threatening ECMO-related drawbacks.

In accordance with the aforementioned recent literature, in case of a potentially reversible condition especially if heart-related, ECLS could be used as a stopgap device until common therapies work, in very selected MPM patients, permitting the recovery and the completion of the multimodal protocol [60, 61].

#### **2.6 Palliative surgery**

The MesoVATS trial is an open-label randomized controlled trial conducted in 12 centres in the United Kingdom, that compared PP by VATS versus talc pleurodesis in *Surgical Management of Malignant Pleural Mesothelioma: From the Past to the Future DOI: http://dx.doi.org/10.5772/intechopen.103686*

patients with MPM [62]. There were no differences between groups in the OS at 1 year nor at 6 months of follow-up. Furthermore, the benefits of VATS-PP (better quality of life, less short-term pleural effusion) do not balance the inconveniences (surgical complications and longer hospital stay leading to more costs). Guidelines strongly recommend talc poudrage via thoracoscopy to control a recurrent MPM effusion as the first choice to achieve pleurodesis in patients with expanded lungs, while weakly suggest, with a low grade of recommendation, palliative VATS-PP to obtain pleural effusion control in symptomatic patients fit enough to undergo surgery who cannot benefit from (or after the failure of) chemical pleurodesis or indwelling catheter [8].

### **2.7 Surgery for MPM relapse**

Recurrence of MPM after multimodality treatment is a common problem. Nevertheless, there has been no established therapy for relapse to date. Major studies about the treatment of recurrent MPM are reported in **Tables 3** and **4**. Over the literature, MPM with distant spread (associated or not with local relapse) is the most frequent pattern of recurrence, mostly in the EPP group, while the PD group showed a higher local-only failure rate [63–71]. A poor prognosis for recurrent MPM after multimodality treatment has been reported in the literature, with a median postrecurrence survival (PRS) after EPP ranging from 3 to 6.5 months [64–66, 72]. Newly,


*MPM: malignant pleural mesothelioma; EPP: extrapleural pneumonectomy; PD: pleurectomy/decortication; NR: not reported; L: local; D: distant; L + D: local+distant.*

#### **Table 3.**

*Major studies about the treatment of recurrent MPM: Multimodality regimen and pattern of failure.*


*MPM: malignant pleural mesothelioma; EPP: extrapleural pneumonectomy; PD: pleurectomy/decortication; NR: not reported; L: local; D: distant; L + D: local+distant; DFS: disease-free survival; PRS: post recurrence survival; OS: overall survival, calculated from the date of surgery, except (a) from the first cycle of neoadjuvant chemotherapy; (b) from the date of pleural biopsy.*

#### **Table 4.**

*Major studies about the treatment of recurrent MPM: Oncological outcomes.*

comfortable PRS were described after PD by Nakamura et al. and Kai and collaborators (14.4 and 20 months, respectively) [65, 67].

Conversely, Bellini and collaborators recently noted that the type of surgical resection did not affect the PRS (14 and 8 months in the EPP and PD group, respectively) if patients are fit enough to receive post-recurrence treatments [71]. Across the literature, the post-recurrence treatment is the main predictor of better PRS [63, 65, 67], in particular, Bellini and co-authors found tailored medical therapies as the best strategy to face relapse, even in the case of local failure [71], in contrast with satisfactory PRS after redoing surgery, which was reported by Kostron et al. [63]. The Italian group cautiously hypothesized that the early local-only failure may likely reflect a less radical local resection that could benefit from timely systemic therapies, rather than redo surgery that is rarely radical in most of the cases [71]. Moreover, several authors reported a long disease-free survival (DFS) (≥12 months) as significantly associated with good survival [61, 67, 71], probably reflecting a slower tumor growth speed associated with a less aggressive recurrent disease. Furthermore, epithelial histology [65, 71] and local recurrence [71] resulted as a favorable prognostic

factor for PRS, the latter may be due to a less deleterious effect on performance status and, consequently, on survival compared with distant spread [71]. In conclusion, in patients presenting with recurrence of MPM after an MCR procedure, radical surgery to resect the recurrent tumor could have a role in the improvement of survival in selected patients [73].
