**12. Discussion**

**Figure 4.** The screen of extracorporeal circulation machine showing in real time all parameters related to the proce‐

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‐

> **Patient Population**

Lang Lazdunski et al 2012 54 23 27,7

Zellos et al 2009 29 20 66

**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.

**Median Overall Survival (months)**

**Complications (%)**

mic pleural chemoperfusion after extrapleural pneumonectomy (table 6), [78], [79].

**Publication Year**

dure (temperature, flow-rate, time).

180 Principles and Practice of Cardiothoracic Surgery

**Study Group**

**Surgical Technique**

P/D and hyperthermic pleural lavage with povidone-iodine

EPP and hyperthermic cisplatin perfusion 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 mean survival [86].

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 superior therapeutically to extrapleural pneumonectomy because these patients were able to undergo even second-line chemotherapy [78].

pemetrexed). The follow-up of patients continues until today and the results are very encour‐ aging. Worth to mention the case of a patient who has completed three years after the start of treatment and continues with a very good performance status. Hopefully soon, after comple‐ tion of these patients study (http://clinicaltrials.gov/ct2/show/NCT01409551), the final results

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

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

183

Photodynamic therapy is a therapeutic method based on the result of the reaction of a compound containing porphyrin to the effect of visible light. The result of this reaction is the direct cellular damage and the initiation of cell apoptosis [66]. A study showed that for unclear reasons, the mean overall survival of patients who have undergone pleurectomy – decortica‐ tion plus photodynamic therapy, is much larger than the group of patients who received extrapleural pneumonectomy plus photodynamic therapy (8,4 VS 25 months) [83]. Reported that the combination of pleurectomy – decortication plus photodynamic therapy has compa‐ ratively much greater mean overall survival. Perhaps, this is potentially related to preservation

Xenograft experiments has shown that low doses of photodynamic therapy can lead to a selective and strong uptake of a circulating macromolecular chemotherapeutic drug in human

In a recent experimental study in pigs, showed that the use of cold-plasma coagulation may help in the treatment of mesothelioma. With this technique we can predetermine the depth of tissue damage (thermo necrosis) from the surface of the lung with the selection of the appro‐

As for any other type of cancer, the treatment options for malignant pleural mesothelioma include chemotherapy, irradiation, surgery, immunotherapy or some combination of these modalities. The choice of treatment is influenced by factors like the extensive nature of this tumor, its proximity to intrathoracic organs and the general medical condition of these patients who are usually older and often have underlying diseases. Most patients due to a lack of large prospective clinical trials are treated in a highly individualized manner. Most reported studies can at best be classified as phase I type. There are very few properly structured phase II studies

The limitations of chemotherapy and radiotherapy have made surgery an important part of multimodality treatment for MPM. Trimodality therapy has recently emerged as a new treatment strategy to improve prognosis. To improve resectability rate and local control, induction chemotherapy is combined with aggressive surgery and post-operative radiother‐ apy. Pemetrexed has been shown to be among the most active agents and is currently used in

Operations for MPM can be divided into two categories – those performed for palliation and those performed with curative intent. Video-assisted thoracic surgery (VATS) with talc

of the lung or some photodynamic therapy -induced effect, or both [90].

malignant mesothelioma xenografts, but not in normal tissue [91].

will be published [77].

priate dose of energy [92].

and no phase III studies at all.

**13. Conclusion**

induction trials.


**Table 8.** All recent studies of extrapleural pneumonectomy (EPP) or pleurectomy - decortication (P/D) or/and combination with hyperthermic pleural chemoperfusion or/and intracavitary photodynamic therapy (PDT) for the surgical treatment of mesothelioma

The results from the application of thoracic cavity lavage with hyperthermic solution and povidone iodide after pleurectomy – decortication, are promising and with fewer complica‐ tions compared to extrapleural pneumonectomy [76]. In a small series of patients that chemo‐ therapy perfusion was performed with cisplatin (100-150 mg / m) at 42 ° C for 1 h, very good results were observed. Specifically, the mean survival rate was 18 months (in combination with radiotherapy and chemotherapy), without serious perioperative complications [89].

In our department, the last three years, we have tried chemotherapy perfusion with peme‐ trexed (500 mg) at 42 ° C for 30 min, after pleurectomy – decortication in seven patients. Their overall treatment included radiotherapy and systemic chemotherapy (carboplatin and pemetrexed). The follow-up of patients continues until today and the results are very encour‐ aging. Worth to mention the case of a patient who has completed three years after the start of treatment and continues with a very good performance status. Hopefully soon, after comple‐ tion of these patients study (http://clinicaltrials.gov/ct2/show/NCT01409551), the final results will be published [77].

Photodynamic therapy is a therapeutic method based on the result of the reaction of a compound containing porphyrin to the effect of visible light. The result of this reaction is the direct cellular damage and the initiation of cell apoptosis [66]. A study showed that for unclear reasons, the mean overall survival of patients who have undergone pleurectomy – decortica‐ tion plus photodynamic therapy, is much larger than the group of patients who received extrapleural pneumonectomy plus photodynamic therapy (8,4 VS 25 months) [83]. Reported that the combination of pleurectomy – decortication plus photodynamic therapy has compa‐ ratively much greater mean overall survival. Perhaps, this is potentially related to preservation of the lung or some photodynamic therapy -induced effect, or both [90].

Xenograft experiments has shown that low doses of photodynamic therapy can lead to a selective and strong uptake of a circulating macromolecular chemotherapeutic drug in human malignant mesothelioma xenografts, but not in normal tissue [91].

In a recent experimental study in pigs, showed that the use of cold-plasma coagulation may help in the treatment of mesothelioma. With this technique we can predetermine the depth of tissue damage (thermo necrosis) from the surface of the lung with the selection of the appro‐ priate dose of energy [92].
