**11. Pleurectomy - Decortication and hyperthermic pleural chemoperfusion / photodynamic therapy**

The later and modern surgical therapy for the treatment of malignant mesothelioma is the combination of radical resection of parietal and visceral pleura (pleurectomy – decortication), by applying hyperthermic pleural lavage (40–41°C), using aqueous solution containing chemical agents such as povidone iodine or chemotherapeutic substances [76].

A newer and more advanced method is the combination of radical resection of parietal and visceral pleura (pleurectomy – decortication), followed by continuous (30min) chemoperfu‐ sion supported by extracorporeal circulation machine, for washing the pleural cavity with hyperthermic (40–41°C), aqueous solution containing chemotherapeutic substances (used also for systemic chemotherapy) [77].

Specifically after pleurectomy – decortication, place two chest tubes in the pleural cavity, ensuring that each is directed anteriorly and top and the other posteriorly and to diaphragm nearby. Usually, the first tube tube need for inflow and the second for outflow. The tubes are connected to a specific extracorporeal circulation machine and create a closed flow circuit, through which the hyperthermic solution circulate and washes the pleural cavity (fig 2-4).

**Figure 2.** The patient is connected to the extracorporeal circulation circuit in order to apply hyperthermic pleural che‐ moperfusion.

**Figure 3.** The arrow shows the direction flow of the hyperthermic solution inside the thoracic cavity.

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**11. Pleurectomy - Decortication and hyperthermic pleural**

chemical agents such as povidone iodine or chemotherapeutic substances [76].

The later and modern surgical therapy for the treatment of malignant mesothelioma is the combination of radical resection of parietal and visceral pleura (pleurectomy – decortication), by applying hyperthermic pleural lavage (40–41°C), using aqueous solution containing

A newer and more advanced method is the combination of radical resection of parietal and visceral pleura (pleurectomy – decortication), followed by continuous (30min) chemoperfu‐ sion supported by extracorporeal circulation machine, for washing the pleural cavity with hyperthermic (40–41°C), aqueous solution containing chemotherapeutic substances (used also

Specifically after pleurectomy – decortication, place two chest tubes in the pleural cavity, ensuring that each is directed anteriorly and top and the other posteriorly and to diaphragm nearby. Usually, the first tube tube need for inflow and the second for outflow. The tubes are connected to a specific extracorporeal circulation machine and create a closed flow circuit, through which the hyperthermic solution circulate and washes the pleural cavity (fig 2-4).

**Figure 2.** The patient is connected to the extracorporeal circulation circuit in order to apply hyperthermic pleural che‐

**chemoperfusion / photodynamic therapy**

for systemic chemotherapy) [77].

178 Principles and Practice of Cardiothoracic Surgery

moperfusion.

**Figure 3.** The arrow shows the direction flow of the hyperthermic solution inside the thoracic cavity.

Futhermore, hypertermic intra-thoracic chemotherapy (HITHOC) can be used even in inoperable patients with clinical stage III-IV, with very good results, mean survival rate 30

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

Also the radical resection of parietal and visceral pleura (pleurectomy – decortication) can be combined with the application of intracavitary photodynamic therapy [81]. The latest, relevant studies are very few and come from the same center. They show very good median survival

> **Publication Year**

P/D - PDT Friedberg et al 2012 38 31,8 P/D - PDT Friedberg et al 2011 14 25

**Table 7.** Recent studies of pleurectomy - decortication (P/D) in combination with intracavitary photodynamic therapy

The main goal of all these combined techniques is the elimination of possible microscopic

Unfortunately, there are not too many recent studies to demonstrate clearly the most appro‐ priate and effective surgical therapy in the treatment of malignant pleural mesothelioma. The latest studies regarding surgical treatment of malignant mesothelioma are presented in table 8. However, some recent studies have tried to answer the question. Apparently, extrapleural pneumonectomy has achieved greater surgically induced cytoreduction and this method was the first surgical approach for many years [84]. Also, studies show that extrapleural pneumo‐ nectomy, when is not complicated, can have a significant and rapid, positive effect on resolu‐ tion of symptoms and improve the quality of life in patients with malignant pleural mesothelioma [85]. It is claimed that co-removal of pericardium and hemidiaphragm should not be applicable to extrapleural pneumonectomy, because this fact increases very much the postoperative complications and the risk of disease seeding, without significantly increase in

However, current studies, that compare extrapleural pneumonectomy and pleurectomy – decortication, showed that extrapleural pneumonectomy had more and larger postoperative complications with worse quality of life, disease recurrence was delayed a little longer, while the median survival did not show a statistically significant difference [69] [70] [87] [88]. Even more, recent studies demonstrated that patients with pleurectomy – decortication were

**Patient Population**

**Median Overall Survival (months)**

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months, because it increases the process of apoptosis [80].

**Study Group**

**Surgical Technique**

residual disease.

**12. Discussion**

mean survival [86].

(PDT) for the surgical treatment of mesothioma.

rate (25 - 31,8 months) and few complications (table 7) [82], [83].

**Figure 4.** The screen of extracorporeal circulation machine showing in real time all parameters related to the proce‐ dure (temperature, flow-rate, time).

Hyperthermic pleural chemoperfusion can be combined with extrapleural pneumonectomy or with pleurectomy – decortication. Two recent studies suggest that the combination of hyperther‐ mic pleural chemoperfusion after pleurectomy – decortication has a better median survival rate (23 VS 20 months) and fewer complications (27,7 VS 66 %) than the combination of hyperther‐ mic pleural chemoperfusion after extrapleural pneumonectomy (table 6), [78], [79].


**Table 6.** Recent studies of extrapleural pneumonectomy (EPP) or pleurectomy - decortication (P/D) in combination with hyperthermic pleural chemoperfusion for the surgical treatment of mesothioma.

Futhermore, hypertermic intra-thoracic chemotherapy (HITHOC) can be used even in inoperable patients with clinical stage III-IV, with very good results, mean survival rate 30 months, because it increases the process of apoptosis [80].

Also the radical resection of parietal and visceral pleura (pleurectomy – decortication) can be combined with the application of intracavitary photodynamic therapy [81]. The latest, relevant studies are very few and come from the same center. They show very good median survival rate (25 - 31,8 months) and few complications (table 7) [82], [83].


**Table 7.** Recent studies of pleurectomy - decortication (P/D) in combination with intracavitary photodynamic therapy (PDT) for the surgical treatment of mesothioma.

The main goal of all these combined techniques is the elimination of possible microscopic residual disease.
