Pleurectomy/decortication for malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a tumour arising from the mesothelial cells lining the pleural cavity. There is an association between environmental asbestos exposure and the development of MPM with an increasing annual incidence in UK of over 2,000 cases per year. The standard treatment is chemotherapy and in some patients additional surgery may have a survival benefit. The role of surgical resection in the management of MPM is still controversial. Recent reports suggest that patients undergoing surgery experienced a longer median survival compared with those without surgery. Two surgical techniques are available, Extended pleurectomy/decortication (EPD) and extrapleural pneumonectomy which is less tolerated. EPD is an operation to achieve macroscopic complete resection of the disease involving resection of the parietal and visceral pleurae, pericardium, and diaphragm without sacrificing the lung. In MPM because of inability to eradicate residual microscopic disease, surgery is cytoreductive rather than radical. Therefore, treatment has focused on surgery in combination with radiation and/or chemotherapy in a multimodality setting. The MARS2 trial was initiated to establish the role of EPD in the setting of multimodal therapy. CT-scan and associated positron emission tomography (PET)-scan are essential for staging the disease and planning surgical strategy. Stage IV patients with diffuse disease or metastatic disease should be excluded from surgery. The EPD is conducted via a single skin incision and single or double thoracotomy. The steps are as follows: (I) dissection and mobilisation of parietal pleura from the chest wall; (II) dissection and mobilisation of mediastinal pleural to separate the tumor from mediastinum; (III) decortication of the lung separating visceral pleura from lung parenchyma; (VI) mediastinal lymph node dissection; (V) anterior, posterior and inferior pericardial resection; (VI) mobilisation and resection of diaphragm; (VII) reconstruction of diaphragm and pericardium; (VIII) closure.