**8. Surgical treatment**

Malignant pleural mesothelioma is a disease that is difficult to be cured. But efforts made, combining various medical specialties such as thoracic surgery, oncology, radiotherapy and pulmonology, to the greatest possible therapeutic approach. In this chapter, the goal is, through the review of contemporary literature, to highlight the modern surgical strategy for treatment of malignant pleural mesothelioma.

Based on the clinical staging of disease and histological type, the treatment strategy should be decided. Specifically, for clinical stage I-III or epithelioid or mixed histology type, the proposed treatment is surgical or combined, whereas for clinical stage IV or sarcomatoid histology type, chemotherapy is suggested [63].

In case that surgical treatment has been chosen, the patient should undergo a careful preop‐ erative evaluation, that includes the following selection criteria [64]:


**•** Ejection fraction > 40%

**Stage Description**

Ia T1aN0M0

Ib T1bN0M0

Stage II T2N0M0

Stage III Any T3M0

Stage IV Any T4

**Table 2.** New International Staging System for Malignant Pleural Mesothelioma (IMIG): Clinical staging (Rusch VW).

Malignant pleural mesothelioma is a disease that is difficult to be cured. But efforts made, combining various medical specialties such as thoracic surgery, oncology, radiotherapy and pulmonology, to the greatest possible therapeutic approach. In this chapter, the goal is, through the review of contemporary literature, to highlight the modern surgical strategy for

Based on the clinical staging of disease and histological type, the treatment strategy should be decided. Specifically, for clinical stage I-III or epithelioid or mixed histology type, the proposed treatment is surgical or combined, whereas for clinical stage IV or sarcomatoid histology type,

In case that surgical treatment has been chosen, the patient should undergo a careful preop‐

erative evaluation, that includes the following selection criteria [64]:

Any N1M0 Any N2M0

> Any N3 Any M1

Stage I

174 Principles and Practice of Cardiothoracic Surgery

**8. Surgical treatment**

chemotherapy is suggested [63].

**•** Predicted postoperative FEV1 > 1.0 L

**•** Performance status 0 – 1

**•** Room air PaO2 > 65 mmHg

**•** Room air PaCO2 < 45 mmHg

treatment of malignant pleural mesothelioma.

**•** Mean pulmonary artery pressure < 30 mmHg

The aim of surgical treatment is to achieve the maximum cytoreduction and radical resection of macroscopic lesions of the disease and includes the following approaches [65]:


### **9. Extrapleural pneumonectomy**

The extrapleural pneumonectomy involves radical excision of the entire lung, en block with the parietal pleura, including the ipsilateral hemidiaphragm and pericardium and radical mediastinal lymph node dissection. The main goal of this surgical technique is to achieve complete exclusion of macroscopic disease [66].

The surgical technique is usually applied with posterolateral thoracotomy. In case of previous incisions (probably for biopsy), all scars should be excluded in order to avoid spreading the disease. Entry into the thoracic cavity is usually made through the sixth intercostal space. To achieve good surgical field, the sixth rib may be excised or a second thoracotomy must be performed below in order to facilitate better resection and reconstruc‐ tion of the hemidiaphragm. After division of the intercostal space, an extrapleural plan is created separating the parietal pleura from endothoracic fascia, carefully, without enter‐ ing the pleural cavity. Usually we begin with blunt and sharp dissection caudal-tocephalad. Particular attention is required during the preparation of parietal pleura to the anatomical area of internal mammary vessels, azygos vein, aorta, esophagus, superior vena cava, inferior vena cava and mediastinum. The pericardium is opened and explored for possible metastases and eventually is resected. The hemidiaphragm is resected with very careful dissection from the peritoneum, without entering the peritoneal cavity. Then a complete mediastinal lymphadenectomy is carried out and ligation of major thoracic duct. Finally in order to complete pneumonectomy, pulmonary artery and veins as well as the main bronchus are ligated. The deficit of the pericardium is restored by placing bovine pericardium, while hemidiaphragm defect restored with synthetic mesh. Finally place a chest tube, followed by closure of the wound in accordance with the anatomical struc‐ tures' class [64], [67].

The complications of this surgical procedure are represented in the table 3 below:


**Table 3.** Complications of extrapleural pneumonectomy

Results obtained from the most recent studies show that the rate of perioperative complications ranges in 50 - 68 %, while the mean overall survival of patients receiving combination therapy which includes extrapleural pneumonectomy ranges 12,8 - 29,1 months (table 4) [68–74].


**Figure 1.** Parietal and visceral pleura after pleurectomy – decortication.

**Surgical Technique** **Study Group**

This surgical procedure is usually performed by posterolateral thoracotomy at the level of the sixth or seventh intercostal space. After opening the selected intercostal space, prepare the parietal pleura in all directions. We should mobilize the parietal pleura to dislodge it from the visceral pleura, where there are adhesions. In next step, visceral pleura is peeled gently away from the lung surface including the interlobar fissures, avoiding produce tears to the under‐ lying lung. After the decortication, may proceed to parietal pleurectomy, carefully, preventing the injury of the brachial plexus, the vagus nerve, the subclavian artery and the sympathetic chain, the esophagus, the thoracic duct, the phrenic and recurrent nerves and hilar blood

Recent Advances in Surgical Techniques for Multimodality Treatment of Malignant Pleural Mesothelioma

The complications of the procedure is primarily bleeding from the detachment of parietal pleura and the many air leaks from the detachment of visceral pleura. In recent studies, the complica‐ tion rate fluctuates between 24 - 43 %, while the mean overall survival of patients with multimo‐

> **Patient Population**

**Median Overall Survival (months)**

**Complications (%)**

http://dx.doi.org/10.5772/53397

177

dality treatment including pleurectomy - decortication ranges 13,5 - 25 months (table 5).

P/D Rena et al 2012 20 25 24 P/D Nakas et al 2012 67 13,4 43

vessels. Finally place two chest tubes, followed by closure of the wound [67].

**Publication Year**

**Table 5.** Recent studies of pleurectomy - decortication (P/D) for the surgical treatment of mesothioma.

**Table 4.** Recent studies of extrapleural pneumonectomy (EPP) for the surgical treatment of mesothioma.

#### **10. Pleurectomy - Decortication**

Pleurectomy and decortication involves the surgical treatment with performance of dissection of parietal pleura from endothoracic fascia, diaphragm and mediastinum (including the pulmonary fissures down to the pulmonary artery and pleural reflections) and decortication of visceral pleura (visceral pleura is peeled away from the lung like the stripping away of a rind), with preservation of lung parenchyma (fig 1). The resection of the parietal and visceral pleura can be partial, radical or extensive (when included excision of the pericardium and / or hemidiaphragm) [75].

**Figure 1.** Parietal and visceral pleura after pleurectomy – decortication.

**Common Complications Unommon Complications** Hemothorax Bronchopulmonary fistula Atrial arrhythmias Patch dehiscence Cardiac tamponade Empyema Cardiac hernia ARDS Chylothorax Pneumonia

Abdominal organs herniation Septicemia Postpneumonectomy Vocal cord palsy pulmonary edema Horner's syndrome

Results obtained from the most recent studies show that the rate of perioperative complications ranges in 50 - 68 %, while the mean overall survival of patients receiving combination therapy which includes extrapleural pneumonectomy ranges 12,8 - 29,1 months (table 4) [68–74].

EPP Bille et al 2012 25 12,8 68 EPP Rena et al 2012 19 20 62 EPP Nakas et al 2012 99 14,7 68

EPP Yan et al 2009 70 20 50

Pleurectomy and decortication involves the surgical treatment with performance of dissection of parietal pleura from endothoracic fascia, diaphragm and mediastinum (including the pulmonary fissures down to the pulmonary artery and pleural reflections) and decortication of visceral pleura (visceral pleura is peeled away from the lung like the stripping away of a rind), with preservation of lung parenchyma (fig 1). The resection of the parietal and visceral pleura can be partial, radical or extensive (when included excision of the pericardium and / or

**Table 4.** Recent studies of extrapleural pneumonectomy (EPP) for the surgical treatment of mesothioma.

**Patient Population**

**Median Overall Survival (months)**

**Complications (%)**

**Publication Year**

EPP Buduhan et al 2009 46 24 EPP Hasani et al 2009 18 20,4 EPP Krug et al 2009 54 29,1

**Table 3.** Complications of extrapleural pneumonectomy

176 Principles and Practice of Cardiothoracic Surgery

**Study Group**

**10. Pleurectomy - Decortication**

hemidiaphragm) [75].

**Surgical Technique**

> This surgical procedure is usually performed by posterolateral thoracotomy at the level of the sixth or seventh intercostal space. After opening the selected intercostal space, prepare the parietal pleura in all directions. We should mobilize the parietal pleura to dislodge it from the visceral pleura, where there are adhesions. In next step, visceral pleura is peeled gently away from the lung surface including the interlobar fissures, avoiding produce tears to the under‐ lying lung. After the decortication, may proceed to parietal pleurectomy, carefully, preventing the injury of the brachial plexus, the vagus nerve, the subclavian artery and the sympathetic chain, the esophagus, the thoracic duct, the phrenic and recurrent nerves and hilar blood vessels. Finally place two chest tubes, followed by closure of the wound [67].

> The complications of the procedure is primarily bleeding from the detachment of parietal pleura and the many air leaks from the detachment of visceral pleura. In recent studies, the complica‐ tion rate fluctuates between 24 - 43 %, while the mean overall survival of patients with multimo‐ dality treatment including pleurectomy - decortication ranges 13,5 - 25 months (table 5).


**Table 5.** Recent studies of pleurectomy - decortication (P/D) for the surgical treatment of mesothioma.
