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In recent years, there has been a shift from extrapleural pneumonectomy (EPP) toward pleurectomy/decortication (P/D) as the preferred surgical technique. However, we occasionally encounter difficult cases wherein visceral pleurectomy requires conversion to EPP from P/D. We sought to clarify the preoperative risk factors and clinical outcomes associated with conversion to EPP. We compared and analyzed conversion to EPP and P/D between September 2012 and December 2019. Conversion to EPP was decided in case of diffuse tumor invasion to the pulmonary parenchyma or due to failure of decortication. Univariable regression analysis was performed to determine the association of preoperative variables with conversion to EPP. Survival was analyzed by the Kaplan-Meier method and log-rank test. Of the 181 patients who underwent intended P/D, 145 (80.1%) patients underwent P/D and 18 (9.9%) patients underwent conversion to EPP. The sum of 3-level pleural thickness (P0.001), maximum of 3-level pleural thickness (P = 0.006), and clinical T stage (P0.001) demonstrated association with conversion to EPP. Overall survival and progression-free survival were significantly worse in the conversion to EPP group (median overall survival, 29.2 months vs 57.0 months [P = 0.008]; median progression-free survival, 15.3 months vs 23.2 months [P = 0.005]. Our data show that approximately 1 of every 10 patients with P/D intention converted to EPP. Preoperative pleural thickness and clinical T stage may be risk factors associated with conversion to EPP. The survival rate of conversion to EPP was worse than that of P/D.

Extrapleural pneumonectomy (EPP) and pleurectomy decortication (PD) are radical operations for malignant pleural mesothelioma (MPM) that remain controversial among thoracic surgeons. There is a lack of randomized evidence to support a survival benefit when major surgical resection is included in multi-modality treatment regimens. Current data from retrospective single institution reviews and prospective trials such as the Surgery for Mesothelioma After Radiation Therapy (SMART) trial are limited by biased patient selection to include only the healthiest patients with most limited disease burden. This patient population predictably has relatively longer survival times than patients with inoperable advanced disease. The only randomized trial to date that has objectively evaluated the true benefit of surgical resection was the Mesothelioma and Radical Surgery (MARS) trial which actually showed shorter survival times among patients who underwent EPP compared with those treated medically. Critics of the MARS trial cite a high perioperative mortality rate for driving these results, however a similar trial has never been repeated to refute the MARS trial results. Finally, it is relevant to consider the high mortality and morbidity rates associated with major operations when recommending these interventions to MPM patients. There is a growing body of literature that identifies patients who clearly obtain no benefit from surgery including those with sarcomatoid or biphasic histology, nodal disease, elevated CRP, elevated platelets and advanced age. Surgery in MPM has risks and is of questionable benefit with outcomes data biased by patient selection of those who will have longer overall survival times regardless of treatment.

Surgery is a mainstay of treatment allowing for debulking of tumor and expansion of the lung for improvement in median survival and quality of life for patients with malignant pleural mesothelioma (MPM). Although optimal surgical technique remains open for debate—extrapleural pneumonectomy (EPP) vs. pleurectomy/decortication (P/D)—minimally invasive surgery (VATS-P/D) remains underutilized in the management of MPM. We examined whether VATS-P/D is a feasible alternative to EPP and P/D. We evaluated the New York Statewide Planning and Research Cooperative System (SPARCS) from 2007–2017 to assess the short-term complications of EPP vs. P/D, including a subanalysis of open P/D vs. VATS-P/D. There were 331 patients with open surgery, 269 with P/D and 62 with EPP. There were 384 patients with P/D, 269 were open and 115 VATS. Rates of any complication were similar between EPP and P/D patients, but EPP had significantly higher rates of cardiovascular complications. After adjusting for confounders, those with a VATS approach were less likely to have any complication, compared to an open approach and significantly less likely to have a pulmonary complication. VATS-P/D remains a viable alternative to radical surgery in MPM patients allowing for improved short-term outcomes.

Background: Radical pleurectomy/decortication (P/D) is applied as a surgical treatment of resectable malignant pleural mesothelioma (MPM). Although P/D removed visceral pleura, dissection plain was not histologically explored previously. We examined a pathological evaluation of surgically removed visceral pleura in P/D. Methods: Twenty-five patients with MPM who underwent P/D at the Tokyo Medical and Dental University Hospital between April 2010 and April 2018 were studied. The 25 cases included 20 with epithelioid tumors, 4 with a biphasic tumor and 1 with desmoplastic tumors. Nine, 1, 11 and 4 patients had mesotheliomas of stages I, II, III and IV, respectively. We analyzed the site of the visceral pleural lesions using the HE & Elastica van Gieson (EVG) staining. The tumor involvement of the pleura and the surgical dissection plane were defined using the depth criteria, D0–3. We added survival analyses according to the depth criteria. Results: Ninety-nine lesions in total 45 lobes: 20 upper right, 14 middle, 20 lower, 22 upper left, and 23 lower were examined. Based on the depth D 0–3 criteria, there were 21 type D0, 18 type D1, 22 type D2 and 38 type D3 lesions. The growth of tumor cells in the pleura was partially diffuse or nodular in all cases. While 38 lesions which invaded the lung parenchyma were excised, another 61 lesions that reached within the pleura were dissected from lung parenchyma. Type D2&3 showed poor survivals than type D0&1. Conclusions: The lung parenchyma was always the dissection plane in P/D, regardless of tumor involvement in the visceral pleura. The depth criteria would help us in classifying pleural invasion histologically and possibly predicting the prognosis.

Background/objectives We evaluated postoperative mortality and complications after extrapleural pneumonectomy (EPP) and pleurectomy decortication (P/D) to better understand their effectiveness in malignant pleural mesothelioma (MPM). Methods A meta-analysis was done to evaluate 30-day mortality and postoperative complications. In addition, in-patients data of 500 eligible patients with MPM who underwent EPP or P/D was extracted from the New York Statewide Planning and Research Cooperative System (SPARCS). Multivariate analyses and propensity matching were used to compare in-hospital mortality and postoperative complications in EPP vs P/D. Results The meta-analysis showed a statistically significant difference in 30-day mortality (5% [95% CI: 4-6] vs P/D 2% [95% CI: 1-3]), proportion of complications (46% [95% CI: 36-56] vs 24% [95% CI: 15-34]) and postoperative arrhythmias (20% [95% CI: 12-31] vs 5% [95% CI: 2-8]) for EPP vs P/D. In-hospital mortality (OR adj : 2.6; 95% CI: 0.86-7.75) and postoperative complications (OR adj : 1.1; 95% CI: 0.68-1.86) were not different in EPP compared with P/D while supraventricular arrhythmia was significantly more frequent after EPP vs P/D (OR adj : 5.2; 95% CI: 2.34-11.33). Conclusions Postoperative mortality, postoperative complications, and particularly supraventricular arrhythmia are less frequent after P/D vs EPP. P/D, a less invasive surgery, may provide a better option when technically feasible for patients with MPM.

Resume Introduction Le mesotheliome pleural malin (MPM) est une tumeur rare, tres agressive, dont l’incidence est croissante. L’amiante en est le principal agent causal. Etat des connaissances Les connaissances sur le MPM ont evolue. La thoracoscopie est l’examen cle du diagnostic. Elle permet de realiser des biopsies pleurales, d’evaluer l’etendue de la maladie et de soulager la dyspnee. Le diagnostic anatomopathologique est egalement mieux codifie avec l’immunohistochimie et la relecture des lames par le groupe Mesopath. Les traitements chirurgicaux a visee curatrice sont la pleurectomie-decortication et la pleuro-pneumonectomie elargie, en association avec chimio et/ou radiotherapie. Ces traitements lourds n’entrainent d’amelioration de survie que chez des patients tres selectionnes. Les autres patients sont pris en charge de facon palliative ou les enjeux sont les douleurs et la dyspnee. Perspectives Le traitement chirurgical radical n’est propose que dans des essais therapeutiques ou dans les traitements multimodaux. Sa place n’est pas etablie de facon formelle. De nouvelles therapies seules ou associees au traitement chirurgical sont a l’etude. Conclusions Dans l’attente d’avancees therapeutiques, la prise en charge chirurgicale du MPM se fait au sein d’equipes specialisees ou le benefice de survie et de qualite de vie est discute au cas par cas.

Background: For most thoracic surgeries (lung resection, esophagectomy) the main purpose of inserting a double lumen tube for lung isolation is providing space for dissection and preventing lung motion by not ventilating (collapsing) the lung undergoing surgery. Objective: In addition, during pleurectomy/ decortication surgeries, the anaesthetist can indirectly perform the dissection of pleura from the lung without scrubbing, gloving or holding the scalpel. Conclusion: This is accomplished by ventilating the lung undergoing surgery, with large tidal volumes while the surgeon provides static traction to the visceral pleura. These phases alternate with one lung ventilation. A detailed account of anaesthesia for pleurectomy/ decortication follows.

Key Clinical Message We describe a case of complete intrathoracic stomach and intestinal herniation after pleurectomy/decortication due to diaphragm reconstruction without mesh. Is reconstruction with mesh always necessary? Can lung sparing obviate the tension on residual diaphragm? These are the questions not well described to which we try to give an answer.

Pleurctomy/decortication [P/D] and extrapleural pneumonectomy [EPP] have a high morbidity. In general, P/D morbidity and mortality is lower than EPP. Complications vary widely. Early diagnosis and aggressive management play a key role in the management of complications. Although complications are difficult to manage, mortality is reasonable in experienced centers.

It is with great interest that we read the two editorials, “Non-ablative hypofractionated hemithoracic radiation—a new standard of care in mesothelioma?” by de Perrot and Cho (1) and “Lung-sparing intensity-modulated radiotherapy in malignant pleural mesothelioma: palliative or potentially radical?” by Botticella and De Ruysscher (2), both addressed to our previous publication on hypofractionation and pleural mesothelioma (3). We thank the physicians for their comments and take the opportunity of responding in this Letter to the Editor.

A 64-year-old male (a building demolition worker) was diagnosed with malignant left-sided pleural mesothelioma, and left-sided pleurectomy/decortication was scheduled. Differential lung ventilation (DLV) was performed during the removal of the visceral pleura by connecting the affected lung to a ventilator and the healthy lung to an anesthesia machine, and then separately ventilating the left and right lungs. Anesthetic management using DLV was successfully established without causing significant changes in oxygenation or circulatory dynamics.

Background: Malignant pleural mesothelioma (MPM) is a rare malignancy that is associated with poor prognosis. The use of pleurectomy/decortication (P/D) surgical approach has received attention as a less invasive lung-sparing approach in comparison with extrapleural pneumonectomy (EPP). Aim: We reviewed the available literature on patients with MPM undergoing either EPP or P/D, in order to evaluate which procedure is superior in terms of survival. Methods: We identified original studies that compared the long-term outcomes of P/D and EPP, from 1990 to 2018. The 30-days and 90-days mortality, along with the 1-,2-,3-,5-year survival and the median overall survival (OS) were the primary endpoints. The complications were the secondary endpoints. Both a fixed and a random effect model were used appropriately. The Q statistic and I2 statistic were used to assess the heterogeneity among studies. Results: Fifteen studies were included (kappa=0.906; 95% CI: 0.801, 1.000), incorporating a total of n=3908 patients treated with either EPP (n=1672) or P/D (n=2236). The 30-day mortality was significantly higher in the EPP group (OR:3.24 [95% CI:1.70, 6.20]; p Conclusion: P/D is associated with enhanced outcomes and should be preferred when technically feasible.

TPS9079 Background: Pleurectomy/Decortication (P/D) with neoadjuvant or adjuvant chemotherapy has become a common lung-sparing surgical approach for MPM. Adjuvant hemithoracic IMPRINT was developed at Memorial Sloan Kettering Cancer Center and safe in a multi-institutional phase II study, with promising survival outcomes. The National Cancer Institute (NCI) sponsored this phase III randomized cooperative group trial to test the efficacy of this lung-sparing trimodality approach for resectable MPM. Methods: Patients with newly diagnosed MPM amenable to P/D are enrolled and undergo P/D followed by adjuvant platinum/pemetrexed (preferred) or neoadjuvant chemotherapy followed by P/D. Patients are stratified by histologic subtype, resection status (R0/1 vs. R2), and center patient volume (≤10 vs. > 10 P/Ds per year). Within 8 weeks after completion of the second modality patients are randomized 1:1 to undergo hemithoracic IMPRINT vs. no further therapy. All IMPRINT contours and treatment plans will be centrally reviewed. A contouring atlas and treatment planning constraints for target structures and organs at risk including acceptable and unacceptable variations and deviations were developed. Photon and proton therapy are permitted. The primary endpoint of the study is overall survival. Secondary endpoints include local failure-free, distant-metastases-free and progression-free survival, treatment-related toxicities (CTCAE v5.0) and change in quality-of-life (EORTC QLQ-C30 mean score changes at 9 months post randomization). The target accrual is 150 patients. This study was activated on January 29, 2020. Over 20 institutions have already committed to opening the study which is open to all National Clinical Trials Network (NCTN) sites. Treatment planning guidelines and helpful hints for photon and proton therapy will be presented. Conclusions: NRG LU-006 (clinicaltrials.gov: NCT04158141 ) is open to accrual. This is the first NRG Oncology randomized phase III trial on MPM and evaluates the use of IMPRINT following lung-sparing P/D and chemotherapy. This project was supported by grants U10CA180868 (NRG Oncology Operations), U10CA180822 (NRG Oncology SDMC), U24CA180803 (IROC) from the National Cancer Institute (NCI). Clinical trial information: NCT04158141.

Background: Malignant pleural mesothelioma (MPM) is an aggressive malignancy with few long-term survivors. Despite the dismal prognosis, hyperthermic intrathoracic chemoperfusion (HITHOC) was shown to improve survival in a selective group of patients. We analyzed the influence of HITHOC following pleurectomy and decortication on postoperative morbidity and overall survival for patients suffering from localized mesothelioma. Methods: From 2009 until 2013, 71 patients with localized pleural mesothelioma underwent pleurectomy and decortication followed by HITHOC with cisplatin and doxorubicin. We analyzed postoperative morbidity, age, overall survival and influence of macroscopic resection on survival. Results: Median patient age was 70 years (range, 65-73 years). Patients having the sarcomatoid subtype of mesothelioma showed a poor median survival of 9.2 months. In contrast, patients having the epithelioid subtype had a median survival of 17.9 months. Patients following macroscopic complete resection had a significantly better survival with 28.2 months compared to 13.1 months in patients with incomplete resection of the mesothelioma (P

Malignant pleural mesothelioma is a cancer of the mesothelial cells lining the pleural sac. Surgery for malignant pleural mesothelioma should be part of a multimodality treatment approach and the aim of surgery should be macroscopic complete tumor resection. Lung-sparing operations, such as extended pleurectomy decortication, have gained increasing popularity in the past decade. This video tutorial illustrates the main steps of extended pleurectomy decortication for the treatment of malignant pleural mesothelioma.

One of the potential disadvantages of conventional pleurectomy/decortication for malignant pleural mesothelioma is the need for opening the pleural sac, which might worsen survival. In this study, we have introduced non-incisional pleurectomy/decortication as an alternative technique that does not require the opening of the pleural sac.

Extended pleurectomy/decortication (EPD) has been formally defined but there remain technical areas of debate between practitioners. This is partly attributable to the relative rarity of this operation which is largely confined to a small number of specialist centres. Nevertheless, there is a widespread acceptance that extended pleurectomy/decortication (P/D) is a realistic and favourable alternative to extrapleural pneumonectomy. There may, however, remain a small number of clinical cases where this more extensive operation may be indicated. Preservation of the lung has widened the selection criteria for this form of radical mesothelioma surgery but there remain important factors to consider when offering extended P/D. In many patients with poorer prognostic factors the less radical operation of video assisted partial pleurectomy may be preferable. However, a randomized trial showed no survival benefit for this operation over simple talc pleurodesis. The future for P/D may also lie in the outcome of the MARS2 randomized controlled trial which will report in the next few years. Meanwhile there is a clinical and ethical dilemma when asked to perform this operation outside of the context of a clinical trial in the face of the lack of high grade evidence. The role of P/D is in one respect expanding but this may be short lived pending the findings of its assessment against non-surgical treatment.

Complete resection is the mainstay of treatment for thymoma. Even for advanced-stage thymoma with pleural dissemination, complete resection with extrapleural pneumonectomy may provide a favorable prognosis. Pleurectomy decortication, a lung-sparing surgery, has been preferably employed in recent years as an alternative surgical procedure for malignant pleural mesothelioma. However, little has been reported about pleurectomy decortication for other malignant tumors with pleural dissemination. Here, we present the first case of thymoma with pleural dissemination for which complete en bloc resection was achieved with extended pleurectomy decortication.

Malignant pleural mesothelioma (MPM) is a relatively rare and aggressive tumor which arises from the mesothelial pleural cells, and is commonly associated with asbestos exposure (1). Currently, there are approximately 3,000 cases per year in the United States, and in Europe its incidence is about 20 cases per million, with large variation between the different countries (2,3). MPM’s peak of incidence in most developed counties is expected between 2010 and 2020 (4,5).

Background This comprehensive meta-analysis was conducted to answer the question as to which procedure, pleurectomy decortication (P/D) or extrapleural pneumonectomy (EPP) is more beneficial to malignant pleural mesothelioma patients' outcome. Methods Original research studies that evaluated long-term outcomes of P/D versus EPP were identified, from January 1990 to January 2014. The combined percent perioperative and 2-year mortality, and median survival were calculated according to both a fixed and a random effect model. The Q statistics and I 2 statistic were used to test for heterogeneity between the studies. Results There were 24 distinct data sets, for a total of 1,512 patients treated with P/D, and 1,391 treated with EPP. There was a significantly higher proportion of short-term deaths in the EPP group versus the P/D group (percent mortality meta estimate; 4.5% vs 1.7%; p Conclusions The reanalysis of the large number of studies comparing P/D to EPP suggests that P/D is associated with a 2 ½-fold lower short-term mortality (perioperatively and within 30 days) than EPP. Pleurectomy decortication should therefore be preferred when technically feasible.

Surgical techniques for treatment of malignant pleural mesothelioma (MPM) have improved over the decades. The main surgical principle was accepted as macroscopic complete resection. This principle was achieved with extrapleural pneumonectomy (EPP) and extended pleurectomy/decortication (P/D). Mortality and morbidity are higher following EPP with supraventricular arrhythmias, pulmonary embolism, bronchopleural fistula and pulmonary failure being the most common, while prolonged air leak is frequent following P/D. Completion of multimodality treatment was also shown to be a prognostic factor. Many different neoadjuvant and adjuvant protocols were applied with limited effect on prognosis. While locoregional recurrence is more common following P/D, EPP patients typically recur in contralateral hemithorax and abdomen. Hemithoracic radiation following EPP was the only effective technique shown to decrease locoregional recurrence. However, neither surgical technique (EPP vs. P/D), nor types of multimodality treatment protocols were found to be prognostic in MPM. Epithelioid histology, metastasis to extrapleural lymph nodes and completion of multimodality treatment were prognostic in most of the series. In conclusion, based on the current evidence, the choice of a less morbid and mortal procedure (P/D) seems to be the logical choice in the treatment of MPM.