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Surgery for Mesothelioma: The Broad Stroke of a Paintbrush Harvey I. Pass MD Stephen A. Banner Professor of Thoracic Oncology Vice-Chairman, Research, Cardiothoracic Surgery NYU Langone Medical Center

The Role of Surgery in Malignant Pleural Mesothelioma | Mesothelioma Applied Research Foundation

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The Role of Surgery in Malignant Pleural Mesothelioma presented by Harvey Pass, MD of NYU at the Mesothelioma Applied Research Foundation's conference in New York, NY on September 28, 2012. www.curemeso.org

Text of The Role of Surgery in Malignant Pleural Mesothelioma | Mesothelioma Applied Research Foundation

  • 1. Surgery for Mesothelioma:The Broad Stroke of a PaintbrushHarvey I. Pass MD Stephen A. Banner Professor of Thoracic OncologyVice-Chairman, Research, Cardiothoracic Surgery NYU Langone Medical Center

2. Surgery for Mesothelioma What is the use of surgery in pleuralmesothelioma? What are the present limitations in decidingwhether a patient should have surgery for pleuralmesothelioma? Why is there so much controversy about surgeryfor pleural mesothelioma? What are the types of operations for pleuralmesothelioma and who are they suited for? What, if anything, should be combined withsurgery for pleural mesothelioma? 3. What Is The Use Of Surgery In PleuralMesothelioma? Diagnosis! The predominanttype of pleuralmesothelioma canonly be accuratelyand consistentlyassessed with aadequate size tissuebiopsy of the pleuralabnormality either bymini-open pleuralbiopsy or by VideoAssisted ThoracicBiopsy 4. What Is The Use Of Surgery In PleuralMesotheliomaEffusion Control Video Assisted ThoracoscopicPleurodesis PleurX or Bard Aspira Catheter 5. But what about trying to possibly cure pleural mesothelioma by involving surgery? 6. What are the present limitations in deciding whether a patient should have surgery for pleural mesothelioma? It is very difficult to cure mesothelioma with surgerybecause The biology of the disease makes it difficult for mesothelioma physicians to accurately tell patients how aggressive the disease and this prevents the physicians from guaranteeing that the disease will not recur shortly after surgery The staging system for pleural mesothelioma is not good The disease usually presents at a more advanced stage The surgery is demanding and patients who can have surgery must have a good performance status The disease usually presents as a combination of solid disease and fluid which contains mesothelioma cells By its very nature, pleural mesothelioma is a diffuse, not a localized disease 7. What are the present limitations in deciding whether apatient should have surgery for pleural mesothelioma? How can we chose patients better for surgery? Clinical Factors: Age, sex, functional status, white blood cell count, platelet count, chest pain Pathologic Factors: Type of mesothelioma, evidence of spread Physiologic Factors: Performance status, heart and lung function Molecular Biology Factors: Gene, protein, RNA and DNA profiles 8. What are the present limitations in deciding whether apatient should have surgery for pleural mesothelioma? The Staging System is not very good Tumor extent is very important The greater the volume of disease, the more difficult to cure Nodal involvement is very important Tumor in the lymph nodes makes it more difficult to cure Metastatic disease must be ruled out Use PET-CT scans to find occult disease 9. Stage 1A 10. Stage 1B 11. Stage 2 12. Stage 2 13. Stage 2 14. Stage 3, T3 15. Stage IV, T4 16. Stage IV, T4 17. Stage II, N0 18. Stage III, N2 19. Stage IV, M1 20. Why is there so much controversy about surgery for pleural mesothelioma? These are big operations in frequently elderlyindividuals There has not been a uniform definition of theoperations so everybody is on the same wavelength There is a bias among mesothelioma physiciansthat NO operation is useful in mesothelioma or CERTAIN operations are not useful in mesothelioma Surgeons who do these operations are only nowbeginning to understand that one size does not fitall 21. What are the types of operations for pleural mesothelioma and who are they suited for? Pleurectomy Decortication (PD: Standard orExtended) Usually less bulky disease Great operation for Stage I mesothelioma Patient remains functional since the lung is spared Risk and Morbidity is lower than EPP Recurrence usually within the same chest Extrapleural Pneumonectomy (EPP) More extensive/Invasive disease where a PD wouldleave non-functional, useless lung Functional status must be very good preoperatively Higher mortality and morbidity than PD butacceptable in expert hands Recurrence is usually outside the same chest 22. Adult Chest Surgery: Sugarbaker et al 23. Adult Chest Surgery: Sugarbaker D et al 24. Resected DiaphragmAtriumSVCPericardiumEsophagus Gortex PatchesA BResected DiaphragmPericardiumCD 25. .the controversy 26. EPP adds nothing! EPP is dangerous EPP has a lot ofcomplications This is a randomized trial You are out of your mind! The Trial only involved 50patients and there wascrossover The mortality rate wasunbelievably highcompared to other centers 27. EPP PDBOSTONUPENN SWISSUCLAAUSSIE UK MSKCCSinaiNYU 28. PDStage I PDT1- T1a tumor limited to ipsilateral T1b What are the evolving thoughts pleura, no involvementof visceral pleurainvolvement of visceral pleuraregarding the approach to the potentiallycytoreducible mesothelioma patient? vs EPD PD Stage IIEPP vs EPD EPPT3 T2Locally advanced butInvolvement of diaphragmatic muscle,potentially resectable tumor invasion of lung parenchyma(i.e. pericardium) Courtesy David Rice MD 29. What is NOT controversial???? 30. YOU MUST COMBINE SURGERY WITH OTHER MODALITIES Chemotherapy either preoperative orpostoperative Documented safety and documented improvedsurvival Radiation Therapy postoperatively and possiblypreoperatively Potentially enhanced local control Intraoperative Therapy Heated chemoperfusion Photodynamic Therapy 31. Finally. If you have surgery for pleural mesothelioma, youmust be followed very closely, usually be CT scans At this time, there arent any good blood tests to really monitor the disease besides SMRP, but stay tuned. Use all the resources at your disposal to hearabout mesothelioma centers and novelexperimental approaches The MesoFoundation is a great resource for this