On June 30, the University of Arizona (UA) Department of Surgery announced the successful use of a radical and intricate form of surgery aimed at treating malignant mesothelioma, a cancer of the protective linings that surround the lungs, heart and abdominal organs.
Called extrapleural pneumonectomy, or EPP, the surgery was performed by Jonathan C. Daniel, MD, a thoracic surgeon, in February of this year. The patient was James Massie.
Dr. Daniel, who accepted the UA staff position in September of 2009, is not only an assistant professor in the Division of Cardiothoracic Surgery at the UA’s Department of Surgery, but is also an Arizona Cancer Center member.
The Arizona Cancer Center, one of 40 across the nation (and the only one in Arizona) designated by the National Cancer Institute (NCI) as a Comprehensive Cancer Center, conducts research at both the UA campus in Tucson and the campus in Scottsdale. The Comprehensive Cancer Center designation is the NCI’s highest ranking.
First used in 1949 to treat tuberculous empyema, the surgical technique involves opening the chest wall from the back and side, and complete excision of the pericardium and diaphragm to totally eradicate the tumor.
Surgery is commonly preceded by chemotherapy and followed by intensity-modulated radiation therapy, or IMRT, a form of highly precise radiotherapy that uses computer-directed linear accelerators to deliver radiation in precise parameters to even more precise locations, allowing higher radiation doses without damage to surrounding tissue.
In Massie’s case, chemotherapy was administered by nationally recognized mesothelioma oncologist Linda Garland, MD, with the radiation administered and supervised by Alexander Chi, MD, both of the UA.
The surgical technique, which can also be used to address non-small cell cancers, is not only highly complex, but requires large amounts of replacement blood, up to 7,500 ml. in some cases. In spite of that, the EPP technique, used 29 times between the years 1959 and 1972, had a surprisingly low hospital mortality rate for such aggressive surgery (31 percent), and a median survival rate of 5 months.
Newer EPP techniques, including a single incision of the sixth rib, combined with pericardial and diaphragmatic reconstruction, have provided for even shorter stays (less than 11 days on average), lower mortality (6 percent) and morbidity (19 percent) rates, a 70 percent survival rate up to one year, and a 48 percent rate up to two years.
Massie’s surgery is the first successful EPP performed in Southern Arizona, and Tucson resident Massie, 65, and wife, Sherry, expect the innovative surgery will add years to James’s life.
Massie, who before his retirement served in the U.S. military as a Marine during the Vietnam War, and also – by virtue of his skill as an exceptional linguist fluent in both Russian and Arabic – as an intelligence analyst and presidential interpreter during the Reagan administration, plans to resume activities like hiking and camping that were precluded by his illness.
The typical prognosis for advanced malignant pleural mesothelioma, or MPM, is about a year, with chemotherapy and/or radiation preceded by surgical tumor removal, adding only about four to six more months. Mesothelioma, which occurs in 3 out of 4 cases in the lungs, kills about 2,500 Americans each year.
Since Massie’s surgery, Dr. Daniel has performed five similar procedures, and together with Dr. Garland, Dr. Chi and UA staff, he hopes to create an outstanding mesothelioma treatment center in the American Southwest.
Reported by the Tuscon Citizen, according to Dr. Daniel, the difficult and intricate nature of EPP makes it preferable that patients stay close to home, rather than traveling. However, up to now this has not been possible, since the best surgical centers offering EPP treatment of mesothelial cancer were located in Boston, Houston or San Francisco.