Surgery in malignant pleural mesothelioma: Extra-pleural pneumonectomy - a critical appraisal

Surgical intervention plays a crucial role in the diagnosis, staging, and treatment of malignant pleural mesothelioma (MPM) and can apply with curative intent using extended pleurectomy/decortication or extrapleural pneumonectomy (EPP). EPP is defined as the en-bloc resection of the pleura, lung, diaphragm, and pericardium, excision of previous biopsy and chest tube sites, and radical mediastinal lymphadenectomy and other lymph nodes such as found in the mammary chain, along the intercostal structure and in the costodiaphragmatic region, as well as reconstruction of the diaphragm and pericardium with prosthetic patches to prevent herniation. It was shown that EPP could be performed with acceptable morbidity and mortality. One of the most complex decisions is the surgical indication. Laparoscopy or contralateral pleuroscopy should be performed in case of suspicion of intra-abdominal or contralateral disease in staging imaging. Mediastinal staging is performed via endobronchial ultrasound or mediastinoscopy to exclude N3 disease. The analysis of prognostic factors to identify patient groups benefitting from multimodality therapy led to the development of different prognostic scores, such as the Multimodality Prognostic Score Technical experience has led to decreased operative times and surgical adaptations that include the reconstruction of the diaphragm and pericardium with mesh in all patients regardless of side, buttressing of the bronchial stump with well- vascularized tissue, and advanced methods of haemostasis including argon beam coagulation and topical haemostatic agents for chest wall bleeding.