Surgery for malignant pleural mesothelioma.

The role of surgery for malignant pleural mesothelioma encompasses the need for rapid diagnosis, preoperative staging and surgical resection, and also the need for a greater biological understanding of this rare and aggressive malignancy. In the multimodality treatment paradigm, the goal of surgery is to provide a macroscopic complete resection (i.e., complete removal of all grossly visible tumor). Two operations have evolved: extrapleural pneumonectomy and pleurectomy/decortication. The former is indicated for patients with advanced locally invasive disease; the latter for patients with more superficial spread of tumor that spares the lung and fissures. If critical mediastinal structures (e.g., aorta and vertebral bodies) are found to be involved at thoracotomy, the tumor is classified as T4, and pleurectomy/decortication is recommended. Despite having more advanced disease, a subset of patients with favorable prognostic factors can experience extended survival by undergoing trimodality therapy with extrapleural pneumonectomy, chemotherapy and/or radiation. The influence of surgery goes beyond diagnosis and resection. Much of what we know about the biology of mesothelioma has been gleaned from studying the surgical pathophysiology, including the delineation of histopathologic subtypes, disease stage stratification with survival, the propensity for local (in contrast to systemic) recurrence, as well as the prognostic effect of epithelial versus nonepithelial cell type, extrapleural nodal involvement, tumor bulk and surgical margins. Pending the discovery of new drugs, the focus of clinical research over the next 5 years will emphasize refinements in patient selection, pathologic staging, molecular staging and other novel adjuvant therapies.