Extended pleurectomy and decortication with resection and reconstruction of pericardium and hemidiaphragm for malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a rare tumor of the visceral and parietal pleura that is most commonly associated with occupational exposure to asbestos. Since tumor biology is both aggressive and highly heterogeneous at histopathological and molecular level, prediction of prognosis and treatment effect remains challenging. Up to date, the best outcome in primary treatment is achieved by a multimodality approach that includes chemotherapy, followed by macroscopic complete resection (MCR). However, due to the morbidity associated with radical surgery and the limited life expectancy, a deliberate allocation to MCR is crucial. While MCR can be accomplished by extrapleural pneumonectomy (EPP) or extended pleurectomy and decortication (EPD), the current preferential treatment is EPD due to its lower morbidity and mortality. The present article describes the surgical perspective of MPM treatment starting off with correct allocation to MCR by applying a multimodality prognostic score (MMPS), followed by a step-wise description of the EPD with resection and reconstruction of pericardium and hemidiaphragm. We highlight the importance of repeated intraoperative biopsies and frozen section of the chest wall, the diaphragm and the pericardium to allow an accurate intraoperative staging and to adapt the surgical procedure in case of multifocal infiltration. Additionally, the prevention of possible pitfalls associated with EPD such as esophageal obstruction by the reconstructed hemidiaphragm or prolonged hospital stay due to persisting air leak are going to be discussed.