Baylor Research: The "Staged Surgical Approach" to Mesothelioma Improves Survival

According to a recent study from Baylor College of Medicine in Houston, certain patients who have been diagnosed with mesothelioma cancer in both the thoracic and abdominal cavities still have a chance of surviving for a longer period of time if their treatment center performs the most effective types of aggressive surgery.

According to the findings of the study, patients who underwent bicavitary cytoreductive surgery, which includes the lung-sparing, extended pleurectomy, and decortication, had a median survival time of 58.2 months. In December, the findings were made available online by the Journal of Thoracic and Cardiovascular Surgery.

The study's authors wrote, "Long-term survival can be achieved with an aggressive, staged surgical approach." Longer survival times are possible for patients with localized disease that responds well to resection and multimodal therapy.

Asbestos exposure is the cause of the rare and deadly cancer known as mesothelioma. It rarely presents with a chest or abdomen diagnosis and typically has a poor prognosis.

Having aggressive mesothelioma surgery in a single cavity can be overwhelming, and having two surgeries in a row is almost unheard of outside of a few specialist centers for mesothelioma, like Baylor.

According to the authors, "reports of bicavitary CRS [cytoreductive surgery] are limited." The only non-case report of patients undergoing staged resection of chest and abdominal mesothelioma comes from our series.

440 mesothelioma patients were evaluated at Baylor College of Medicine between 2014 and 2021, and the outcomes of their surgeries varied. Only 14 of them, or 3%, underwent the two-stage chest and abdominal procedures. Six extrapleural pneumonectomy patients and eight extended pleurectomy decortication patients were among the 14 bicavitary patients.

All 14 underwent the standard peritonectomy and hyperthermic intraperitoneal chemotherapy, also known as HIPEC, for the subsequent abdominal surgery.

Between the two operations, six of the patients received chemotherapy, and five of them received adjuvant chemotherapy after each operation.

The cohort as a whole had a median overall survival of 33.6 months and a 20% five-year survival rate.

The retrospective study sought to determine whether bicavitary resection was more effective with the most recent extended pleurectomy decortication procedure or with the older, lung-sacrificing extrapleural pneumonectomy. The outcomes were in no way comparable.

After the second surgery, the median overall survival was only 13.5 months for the EPP group and 58.2 months for the extended P/D group. The median progression-free survival was 12.9 months, compared to 26.3 months for the EPP group and 26.3 months for the ePD group, respectively.

Baylor, like many specialty centers treating mesothelioma, has moved away from the once-groundbreaking EPP surgery that was popularized by the well-known thoracic surgeon and mesothelioma specialist Dr. David Sugarbaker. The findings of the study are one reason why.

Sugarbaker, who spent more than two decades at Brigham and Women's Hospital in Boston and came to be known as Mr. Mesothelioma, was appointed director of The Lung Institute at Baylor Medical Center in 2014. 2018 saw his passing.

According to the authors, "the choice of operative procedure reflects a shift from EPP to ePD in our institution, which is comparable to many mesothelioma centers." The majority of our patients now receive EPD as our standard treatment.

Comparing the two surgeries revealed comparable survival times for pleural mesothelioma in the thoracic cavity, but the ePD had a quicker recovery time and a lower morbidity rate.

After the first surgery, none of the 14 patients in this study died right away, and they all went on to the second one. Two patients, both of whom started with the EPP, passed away within the first ninety days of the abdominal surgery.

According to the authors' conclusion, "We would recommend only performing ePD and avoiding EPP in this cohort of patients when considering bicavitary cytoreductive surgery for mesothelioma."

Dr. R. Taylor Ripley, a thoracic surgeon at Baylor Medical Center, was the study's lead author. Dr. Paul Sugarbaker, a surgical oncologist who was a pioneer in advancing treatments for peritoneal mesothelioma and was the brother of Dr. David Sugarbaker, was one of the co-authors. MedStar Washington Hospital Center was where he last worked.

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