• Mesothelioma
• Pleural Disease
• Thoracic Surgery

The role of surgery in malignant pleural mesothelioma remains a contentious issue. This randomised control trial compared two palliative interventions: cytoreductive surgery versus talc pleurodesis in patients with suspected or confirmed malignant mesothelioma and pleural effusion.1 The authors hoped to show an improvement in survival for video assisted thoracic partial pleurectomy (VAT-PP) and compare cost and symptom control in both interventions.

At 12 months, 45/87 (52%) of patients in the VAT-PP cohort were alive compared with 50/88 (57%) patients receiving talc pleurodesis with a median survival of 13.1 and 13.5 months, respectively. Both interventions resulted in significant resolution of pleural effusion with VAT-PP offering 70% resolution at 12 months and talc pleurodesis 77%. Impact on quality of life was assessed using the EQ-5D self report questionnaire. VAT-PP was associated with relatively improved scores at 6 and 12 months of 0.08 points (p=0.042) and 0.22 points (p=0.006), respectively. However, in the domains of ‘functional scale scores’ and ‘symptoms scale score specific to lung cancer’, there were no significant differences between the two. The mean total cost at 1-year follow-up was £14 246 for VAT-PP and £10 442 for pleurodesis with a greater length of hospital stay for VAT-PP. As expected, VAT-PP was associated with more adverse effects.

The authors conclude that as 78% of patients in the study presented with advanced malignant pleural mesothelioma, VAT-PP may offer benefit in survival in patients with less advanced disease. However, I believe this study supports us to more confidently recommend a less invasive approach and so reduce potential harm and unnecessary reduction in quality of life in this frail patient cohort.