Performing surgery for malignant pleural mesothelioma “is like scraping paint off a wall: there is always going to be microscopic disease left,” declared Joseph S. Friedberg, MD, Chief of Thoracic Surgery at Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, Pennsylvania.“The reason that this colossal operation to remove the pleura from mesothelioma does not cure people is that you cannot get a negative margin here,” he explained. Therefore, surgery remains investigational for patients with this incurable cancer and must be coupled with another modality, such as chemotherapy, radiation therapy, or perhaps intraoperative use of photodynamic therapy (PDT), to treat the residual microscopic disease.
Almost exclusively caused by exposure to asbestos or occasionally a delayed response to radiation, malignant pleural mesothelioma is associated with a poor median survival of 9 to 10 months.1,2 Chemotherapy is arguably the standard of care, although it yields only a 40% response rate and a several-month extension in median survival.1 The modality most likely to be associated with prolonged remission is surgery, although it remains investigational.1
From the perspective of a thoracic surgeon with experience in performing surgery-based treatment for malignant pleural mesothelioma (Figure 1), this article first briefly explores the move from lung-sacrificing to lung-sparing surgery. Then, the University of Pennsylvania experience with lung-sparing surgery plus PDT is explored, showing preservation of quality of life when compared with lung-sacrificing surgery, and promising survival results. Finally, several avenues of PDT-inspired translational research are highlighted by Dr. Friedberg, including the fungicidal effects of PDT in the treatment of pulmonary aspergilloma; preclinical studies using mineral oil to enhance the delivery of light with PDT to illuminate an entire organ; and the use of rare earth nanophosphors for simultaneous radiotherapy and PDT for tumors of the chest cavity, brain, or spinal cord.
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Friedberg JS, Culligan MJ, Mick R et al. . Radical pleurectomy and intraoperative photodynamic therapy for malignant pleural mesothelioma. Ann Thorac Surg 2012;93:1658–1667.
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Friedberg JS, Skema C, Burdick J et al. . A novel technique for light delivery through branched or bent anatomic structures. J Thorac Cardiovasc Surg 2003;126:1963–1967.