Lung-Sparing Surgery Plus PDT Shows Mesothelioma Promise

Author: University of Pennsylvania School of Medicine
Published: 9 Jun 2011 - Updated: 1 Oct 2026
Publication Details: Peer-Reviewed | Reports & Proceedings

Table of Contents:
Synopsis - Definition - Overview - FAQs - Insights, Updates - Related Content

Synopsis

This research from the Perelman School of Medicine at the University of Pennsylvania compared two surgical approaches for pleural mesothelioma, each paired with photodynamic therapy, a light-based cancer treatment given during the operation. Of 28 patients, 14 had a modified extrapleural pneumonectomy, which removes the lung, and 14 had a radical pleurectomy, which keeps it. Median overall survival was 8.4 months in the lung-removal group. In the lung-sparing group, median survival had still not been reached at a follow-up more than two years after treatment. The peer-reviewed findings were published in the Annals of Thoracic Surgery. They matter most to older patients and those with advanced disease, who are often ruled out of surgery altogether. Keeping both lungs lowers surgical risk and makes it far more likely that a patient can return to normal daily life. Thoracic surgeon Joseph Friedberg, MD, who performed the operations, said the survival difference caught the team off guard and that the lung-sparing technique has since become the backbone of Penn's surgery-based treatment.*

At a Glance

• 1 - Patients in the study ranged in age from 27 to 81 and included 19 men and nine women.
• 2 - Advanced Stage III or IV disease was present in 12 of 14 patients, or 86 percent, in both surgical groups.
• 3 - At the time of the study, Penn was one of only two centers in the world using photodynamic therapy to treat pleural mesothelioma.
• 4 - Unlike radiation, which passes through the body, photodynamic therapy penetrates only a short distance, which allows the lung to be preserved.

Topic Definition

Photodynamic Therapy

Photodynamic therapy, often shortened to PDT, is a cancer treatment that uses a light-sensitive drug and a specific wavelength of light to destroy cancer cells. The patient is first given the drug, called a photosensitizer, which collects in tumor tissue. When that tissue is exposed to laser light, the drug reacts with oxygen and produces a form of oxygen that kills nearby cells. Because the light reaches only a short distance into tissue, PDT can treat surface layers of cancer while sparing the healthy organs underneath. In pleural mesothelioma it has been used during surgery, after the visible tumor is removed, to target microscopic disease left on the lining of the chest.

Overview

Combination therapy shows promise for rare, deadly cancer caused by asbestos - Photodynamic therapy added to lung-sparing surgery provides superior results for overall survival in mesothelioma patients.

Pleural mesothelioma patients who undergo lung-sparing surgery in combination with photodynamic therapy (PDT) show better overall survival than patients treated with the conventional therapy of extrapleural pneumonectomy (EPP) (or en bloc removal of the lung and surrounding tissue) with PDT, indicates research from the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania. The research is published in the June 2011 issue of the Annals of Thoracic Surgery.

"Unlike patients who receive traditional lung sacrificing surgery for mesothelioma, the patients in our study who underwent lung-sparing surgery and photodynamic therapy, a light-based cancer treatment, have experienced unusually long overall survival rates. The median survival for those patients was not reached at over two years when the results were analyzed. That's unusual in this field, especially when most of those patients are older and have advanced cancer," said Joseph Friedberg, MD, co-director of the Penn Mesothelioma and Pleural Program and the thoracic surgeon who performed the operations cited in the study.

"In addition to the overall survival statistics, the difference between having and not having a lung, both concerning the risk of surgery and the ability to enjoy a normal life after surgery, is crucial for these patients."

Mesothelioma is one of the most aggressive and deadliest forms of cancer and is usually caused by exposure to asbestos. Exposure to asbestos typically precedes the development of cancer by anywhere from 10 - 50 years, but once it occurs, the average survival following diagnosis is often only 9-12 months.

Although mesothelioma can occur in other locations like the abdomen, pleural mesothelioma is the most common disease and accounts for roughly 70 percent of cases. This form originates in the pleura - the membrane surrounding the lung and lining the chest - where it starts off as a microscopic sheet of malignant cells that coats the chest's interior and can grow several inches thick. The cancer's coating and enveloping nature makes it impossible to remove completely with surgery alone. As a result, the conventional surgery-based approach to treatment involves radical surgery that includes removing the lung and chemotherapy and whole chest radiation. Even with this aggressive treatment, the disease will recur in almost all patients.

The current study had two goals.

• The first was to determine if using a new combination of PDT and surgery would allow a less extensive surgical procedure to be used instead of an EPP.
• The second was to determine if, based on previous research from Penn with PDT, the treatment would have any positive effect on survival for patients.

Unlike radiation, which passes through the body, the PDT therapy used in the current study penetrates only a short distance which allows the lung to be preserved. The PDT treatment aims to eradicate the remaining microscopic disease and may trigger the patient's immune system to help fight the cancer.

In the study:

• 28 patients (19 men, nine women) underwent surgical resection plus PDT for pleural mesothelioma.
• Patients were aged from 27 to 81 years.
• All patients were seen in a multidisciplinary setting and educated about the spectrum of treatment options available, including surgical intervention and its current investigational status.
• Of the study group, 14 patients were treated by modified extrapleural pneumonectomy (MEPP) and 14 by radical pleurectomy (RP) and intraoperative PDT.
• Twenty-two of the 28 patients also received chemotherapy.

Demographics in the MEPP and RP cohorts were similar in age, sex, stage, nodal status, histology, and adjuvant treatments.

Stage III/IV disease was present in 12 of 14 patients (86 percent) in both groups.

The median overall survival for the patients who received the MEPP treatment was 8.4 months.

At a follow-up 2.1 years after the end of treatment, a median survival for the patients who received a radical pleurectomy had not yet been reached. The results yielded by the radical pleurectomy and adjuvant PDT were superior to other studies of surgical treatment plans with patients of similar demographics.

"Our primary motivation in attempting the lung-sparing surgery was the preservation of quality of life, and we were hoping the survival results would at least be similar to the more traditional pneumonectomy approach," said Friedberg. "Although our pneumonectomy results were in line with what is often reported for similar patients having surgery-based treatments, we were completely caught off guard when the analysis revealed a significantly longer survival for the patients who retained both lungs."

Although all patients in the current study received the PDT therapy in combination with a different surgical technique, the researchers further note that the use of intraoperative PDT is the evident difference between the multimodal protocol used in the current study and other standard treatment options presently in use. It seems worth speculating on any potential direct contributions of the PDT to the overall survival rates.

"Why this is happening is unclear and has emerged as the focus of our continuing research," said Friedberg. The residual PDT-treated microscopic disease possibly induced an autologous tumor vaccine effect or enhanced the effect of adjuvant treatments.

"This study has limitations, as many mesothelioma studies do, but these results are very encouraging. The findings from our study are particularly notable because many of the patients in this study would often be excluded from surgery-based therapy because of their advanced age or unfavorable oncologic characteristics such as the large bulk of their cancers or the spread to the lymph nodes" said Dr. Friedberg. "Based on these results, this lung-sparing technique, combined with photodynamic therapy, has become the backbone of our surgery-based treatment protocols."

The Penn Mesothelioma and Pleural Program is a unique program with a multidisciplinary team of dedicated specialists with a passion and expertise for treating patients with these difficult cancers. The Penn Program offers a truly multidisciplinary approach, presenting patients with essentially all treatment options offered worldwide, and several treatments offered only at Penn.

Frequently Asked Questions

NOTE: Researched FAQs by Disabled World (DW)

How does photodynamic therapy kill cancer cells?

A light-sensitive drug is given before treatment and collects in cancer tissue. When laser light of a specific wavelength shines on the area, the drug produces a reactive form of oxygen that destroys nearby cancer cells.

What are the side effects of photodynamic therapy?

The most common side effect is sensitivity to light, which can last several weeks and requires patients to avoid direct sunlight and bright indoor light. Swelling, pain and inflammation in the treated area can also occur.

Is photodynamic therapy an approved treatment for mesothelioma?

Photodynamic therapy is approved in the United States for certain esophageal and lung cancers, but its use for mesothelioma is considered investigational and is offered mainly through clinical trials at specialized centers.

What is the difference between a pleurectomy and an extrapleural pneumonectomy?

A pleurectomy removes the diseased lining of the lung and chest while leaving the lung in place. An extrapleural pneumonectomy removes the entire lung along with the lining and often parts of the diaphragm and the sac around the heart.

Who is a candidate for mesothelioma surgery?

Surgery is usually considered for patients whose cancer has not spread widely, who have the more treatable epithelioid cell type, and who are healthy enough to tolerate a major operation. A specialist team makes the decision case by case.

How long is recovery after lung-sparing mesothelioma surgery?

Most patients stay in the hospital for one to two weeks and need several more weeks to months to regain strength. Recovery is generally easier than after surgery that removes a lung.

Can a person live a normal life with one lung?

Many people adapt to living with one lung, but they often have reduced stamina and shortness of breath with exertion. This is one reason surgeons increasingly favor lung-sparing operations when possible.

Are there non-surgical treatments for pleural mesothelioma?

Yes. Chemotherapy and immunotherapy are the main treatments for patients who cannot have surgery, and radiation therapy and fluid drainage procedures are used to relieve symptoms.

Insights, Analysis, and Developments

Editorial Note: A 28-patient study that was not randomized cannot settle how mesothelioma should be treated, and the researchers said as much. They also could not explain why patients who kept their lungs lived longer. One idea is that photodynamic therapy acts on the microscopic cancer left behind and prompts the patient's own immune system to attack it, working something like a vaccine made from the tumor itself. Twenty-two of the 28 patients also received chemotherapy, which makes it harder to credit any single part of the treatment. Since 2011, mesothelioma surgery in general has moved toward lung-sparing operations, and later trials have raised questions about how much major surgery adds for some patients. Anyone weighing an operation should ask a specialist center how these results apply to their own stage, cell type and overall health.*

Attribution/Source(s): This peer reviewed publication was selected for publishing by the editors of Disabled World (DW) due to its relevance to the disability community. Originally authored by University of Pennsylvania School of Medicine and published on 9 Jun 2011, this content may have been edited for style, clarity, or brevity.

* Editorial additions by Ian C. Langtree.