Editors Note:
This is the last installment in our recent four part series on mesothelioma, the asbestos caused cancer.  In the first part we explored Mesothelioma Survivors and the Immune System and discussed the role that the immune system may play in this cancer.  In Mesothelioma and Virotherapy, we reported on cutting edge research into how viruses may be engineered to treat mesothelioma.  And in Mesothelioma and Molecular Pathways, we discussed how cellular signaling pathways may be used to target mesothelioma by depriving it of the signals it uses to grown and spread.  In the present article, Cancer Monthly’s staff reporter Jeni Baker spoke with prominent thoracic surgeon David J. Sugarbaker about the goal of primary surgery in multimodality therapy for pleural mesothelioma.

   Dr. Sugarbaker

The adage Less is more does not necessarily apply when it comes to surgery for pleural mesothelioma. In fact, more extensive surgery can give some patients the best shot at increased longevity and quality of life.

In a 2006 article*, thoracic surgeon David J. Sugarbaker, MD, of Brigham and Women’s Hospital stated that the goal of surgery for pleural mesothelioma should always be the complete removal of all tumor tissue visible to the naked eye.

A complex disease, an ongoing debate

“Because mesothelioma can take on many forms and involve different parts of the lung, people have been comparing apples and oranges for many years” when weighing the pros and cons of surgeries for the disease, says Sugarbaker.

“We’re used to asking, ‘Do we perform a more extensive procedure or a more conservative one?’ when it comes to surgery, but that debate doesn’t apply as much to mesothelioma,” he says. “The goal should always be to remove all of the visible cancer, and then to follow the surgery with drugs that kill the cancer cells that we couldn’t see.”

The fewer mesothelioma cells that remain, the fewer cells post-surgical drug therapies will be tasked with killing – which is clearly a good thing.

What surgeons should strive for, Sugarbaker says, is a macroscopic complete resection (MCR). A few brief definitions may help explain the issue:

• Macroscopic complete resection (MCR) – The surgical removal of all tumor tissue visible to the human eye

• Extrapleural pneumonectomy (EPP) – The surgical removal of the affected lung, the covering of the heart, and the diaphragm

• Pleurectomy (P/D) – Also known as decortication, the surgical removal of tumors confined to the surface (cortex) of the lung

• Pleural mesothelioma – Mesothelioma that occurs inside the chest cavity, and makes up 90% of cases of the disease

Some tumors are limited to the surface of lung, and in those cases, MCR often can be achieved with a pleurectomy, explains Sugarbaker. But for patients with tumors that have grown down into the fissures of the lung, between the lobes, an EPP – a much more extensive procedure – may be the best choice.

“Physicians familiar with the disease process of mesothelioma understand that EPPs are not interchangeable with pleurectomies,” he says.

“The needs of the patient must drive the procedure”

So where does this leave people diagnosed with mesothelioma?

“They should understand that if a surgeon performs only one type of operation to remove mesothelioma, that surgeon may not be able to provide the most appropriate treatment for them,” Sugarbaker stresses. “Because each procedure requires specialized knowledge and experience, patients with a potentially removable tumor should look for a surgeon skilled at performing whichever procedure is necessary to achieve MCR.”

In short, “the needs of the patient – not the services offered by the surgeon – must always drive the procedure that is chosen,” he says. “My research has shown that when treated appropriately for their disease state, mesothelioma patients can live for a long time – which tells us that appropriately selected surgical procedures can make a difference.”

* Sugarbaker, DJ. Macroscopic Complete Resection: The Goal of Primary Surgery in Multimodality Therapy for Pleural Mesothelioma. J Thorac Oncol, 2006 Feb;1(2):175-6.