Page 23 - Read Online

Housman et al. J Cancer Metastasis Treat 2021;7:69 https://dx.doi.org/10.20517/2394-4722.2021.159 Page 7 of 12

Figure 2. Difference in median survival between extrapleural pneumonectomy and pleurectomy decortication among 17 studies [38] .

[37]
These findings were mirrored in an earlier meta-analysis by Cao et al. . In a systematic review
encompassing 632 EPP, and 513 P/D patients, the morbidity rate was 62.0% for EPP vs. 27.9% for P/D, and
[37]
the mortality rate was 6.8% for EPP vs. 2.9% for P/D . Overall median survival for EPP was 12-22 months,
while P/D was 13-29 months.

A single-center, 10-year experience published by Aziz et al. examined 302 patients with MPM. Of the
[39]
total, 191 received palliative care, 47 patients were treated with P/D, and 64 patients underwent EPP, the last
51 of which also received intrapleural and adjuvant systemic chemotherapy. Median survival was 35
[39]
months . Survival was 8.9 months for patients receiving chemotherapy alone, 13 months for EPP, and 14
months for P/D. Patients treated with EPP and adjuvant chemotherapy had a median survival of 35 months.
Unfortunately, EPP was also associated with a 9% mortality rate compared to 0 following P/D for an OR of
10.56, one of the largest in the literature [39,40] .

Any possible, and yet unproven, benefit that the greater radicality of EPP may offer is not balanced by a
clear survival benefit, even when surgery is successful [13,38,40] . There is insufficient evidence even to prove that
the resection of the diaphragm or pericardium improves outcomes .
[6]

The advantage of P/D over EPP has been shown even when performed in less healthy subjects .
[36]
Luckraz et al. performed a retrospective study of 139 patients undergoing surgery for mesothelioma. They
[36]
showed that despite more advanced disease and less fit patients, P/D with adjuvant chemoradiotherapy was
the strongest predictor of longer survival (HR = 3.6). Worse, controlling for other factors, EPP was found to
[36]
be an independent risk factor for decreased survival .
This pattern is at least partially explained by postoperative lung volumes and ventilatory dynamics.
Bölükbas et al. found that there was a significant improvement in both FVC and FEV following P/D,
[41]
1
even in patients who underwent diaphragmatic resection. The average increase in FEV was 23.9%, with a
1
higher relative increase in patients with poorer preoperative pulmonary function. While this observation
codifies the virtue of P/D as a palliative procedure, it also helps explain post-surgical resilience. Preserved
cardiopulmonary function following P/D permits both more opportunities for adjuvant therapy and confers