Video-assisted thoracoscopic surgery in the management of mesothelioma

Mesothelioma is inevitably a terminal diagnosis and management is focused on palliative treatments that may improve prognosis. The role of surgery in the management of mesothelioma remains controversial as the prognostic benefit has not clearly been demonstrated. Invasive procedures such as extrapleural pneumonectomy (EPP) and pleurectomy/decortication are advocated by some, but the prognostic benefit versus significant perioperative morbidity and mortality is questioned by many. Video-assisted thoracoscopic surgery (VATS) has evolved significantly, and with the reduced perioperative morbidity when compared to open surgery has an increasing and important role in the management of mesothelioma as part of the multidisciplinary palliative management of this disease. VATS has a role as a diagnostic tool providing tissue for a histological diagnosis. VATS is also useful for draining pleural effusion to facilitate lung re-expansion and achieve pleurodesis with talc poudrage—which has been shown to contribute to prolonged survival and improved quality of life. For patients with trapped lung with a low disease burden VATS pleurectomy/decortication could be performed as an alternative to the more invasive open procedures and has significantly lower morbidity/mortality, but the value in terms of improved prognosis of this procedure has been put into question by the conclusions of the MesoVATS study making the role of VATS pleurectomy/decortication now unclear, although the Mesotrap study is underway and its conclusions awaited.