Dr. Ahmet F. Işık talks about pleural mesothelioma, HITHOC, and thoracic surgery in Gaziantep, Turkey

updates on the on-going HITHOC project, war surgery, foreign body obstructions and bronchoscopy for infants

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Gaziantep, Southeastern Anatolia 

antep

It’s been over a year since I first read Dr. Isik’s work on treating pleural mesothelioma.  Since that time, Dr. Işik has continued his research into HITHOC and has now enrolled over 79 patients into the hyperthermic treatment group including one of the patients I met during my visit.  (There are 29 surviving patients in the study, 13 in the mesothelioma group, the remainder are secondary pleural cancers.).

(If you are a patient seeking treatment, or would like more information about Dr. Isik (or Dr. Gonzalez Rivas, Dr. Sihoe or any of the other modern Masters of thoracic surgery), we  are happy to assist you.  Contact me at kristin@americanphysiciansnetwork.org

First impressions are deceiving

I don’t know what I expected Gaziantep to look like as one of the world’s oldest cities, but from the moment the airplane begins its descent into a beige dust cloud, to the desolate brush and dirt of the airport outside the city, it isn’t what I expected.  Much of the antiquity of the biblical city of Antiochia has been replaced by a bustling modern city.  Historic ruins and ancient Roman roads marking this as part of the original Silk Road are conspicuous, only by their scarcity.

modern Gaziatep is featureless at first glance
modern Gaziantep is featureless at first glance

There are a handful of museums and monuments to the area’s rich history, but like the new name of Gaziantep (replacing Antep after the first world war), Turkey’s sixth largest city is modern; a collection of traffic and squat square buildings of post-modern architecture.

Kale
Kale

The city is also a mosaic of people.  There are groups of foreign journalists in the lobby of our hotel, and convoys of United Nations vehicles cruising the streets.  Crowds of Syrian children play in the park, calling out in Arabic to their parents resting on the benches nearby.  There is a smattering of Americans and English speakers interspersed, many are college students and other foreign aid workers on humanitarian missions to help alleviate the strain caused by large numbers of people displaced by the Syrian civil war.

Gaziantep is famed for their copper work
Gaziantep is famed for their copper work

But like a mosaic, there is always more to see, the closer you look.  For me, as I look closer, I just want to see more.  I feel the same about Dr. Elbeyli’s thoracic surgery department.

The closer you look, the more you see. photo courtesy of wiki-commons
The closer you look, the more you see.
photo courtesy of wiki-commons

The border (and the largest Syrian city of Aleppo) lies just to the south – and the impact of the Islāmic militants is felt throughout the region.  No where is this more evident than at the local university hospital, where I meet Dr. Ahmet Işık and the Chief of Thoracic Surgery, Dr. Levent Elbeyli.

with Dr. Elbeyli (left) and Dr. Isik
with Dr. Elbeyli (left) and Dr. Isik

Dr. Ahmet Feridun Işık

I like Dr. Işık immediately.  He is friendly and appears genuinely interested by my visit.  He’s from Giresun in the Black Sea region of northern  Anatolia of Turkey.  He attended medical school at Ankara University and completed his thoracic surgery training in Ankara before going to Adiyaman State Hospital in the bordering Turkish province of Adiyaman in southeastern Turkey.

He was an associate professor of thoracic surgery at Yuzuncu Yil University in the far eastern province of Van, Turkey before coming to Gaziantep in 2005.  He became a full professor at the University of Gaziantep in 2013.  In additional to authoring and contributing to his own publications, he also served as a reviewer for the Edorium series of open access journals.

It helps that his English is miles better than my non-existent Turkish.  (Reading about the Turkish language in phrase books is one thing, pronouncing words correctly is another.)

He doesn’t seem to mind my questions tumbling out one after another.  I’d like to be the cool, sophisticated visitor, but I’ve been waiting so long to ask some of these questions – and frankly, I am just excited to be there.

Dead-ends in medicine

There are a lot of “dead ends” in medicine – treatments that at first appear promising, but then end up being either impractical or ineffective.  In fact, for the first ten years of HIPEC, most surgeons dismissed it as a ‘dead-end’ treatment; the surgery was too radical and mortality too high.  But researchers kept trying experimental protocols; tweaking medications (less toxic) and procedures – and finding the right patients (not too frail prior to surgery) – and the literature shifted; from a largely useless ‘last ditch’ salvage procedure to a large, but potentially life-saving treatment. HITHOC is HIPEC in another color…

So I fire away –

Since our last post about Dr. Işık – he has performed several more cases of HITHOC on patients with pleural mesothelioma, pleural based cancers and advanced lung cancers.  He now has 79 patients in the HITHOC treatment group.  He has been receiving patients from all over Turkey, including Istanbul to be evaluated for eligibility for this procedure.  While the majority of patients are referred by their oncologists, others come to Gaziantep after reading about Dr. Işık on the internet.

None of the original patients (from 2009) are still alive, but their survival still exceeded all expectations, with 13 patients (of 14 HITHOC patients) living 24 to 36 months after the procedure.  (I don’t mean to be vague – but I was asking some of these questions in the operating room and I forgot to stuff my little notebook in my scrub pocket.)

While much of the literature surrounding the procedure cites renal failure as one of the major complications of the procedure, Dr. Işık has had one case of renal failure requiring dialysis.  Any other instances of elevated creatinine were mild and transient.  He doesn’t use any chemical renal prophylaxis but he does use fluid rehydration to limit nephrotoxicity.

He reports that while many surgeons consider sarcomas to be a contraindication to this procedure, he has had good outcomes with these patients.

He does state that diaphragmatic involvement in mesothelioma is an absolute contraindication because while the diaphragm can be resected / patched etc, it is almost impossible to guarantee or absolutely prevent the seeding of microscopic cancer cells from the diaphragm to the abdominal cavity – which increases the risk of disseminated disease.

He still uses Cisplatin – since that is what the original HITHOC researchers were using, but he uses a slightly higher dose of 300mg.  He’d like to do some prospective studies utilizing HITHOC (these have all been retrospective in nature – comparing today’s patients with past patients that received PDD and pleurodesis for similar conditions).  Prospective studies would allow him to better match his patients and to compare treatments head to head.  It would also allow him to compare different techniques or chemotherapeutic agents.

Unfortunately, as he explained, many of these types of studies of ineligible for government funding in Turkey because the government doesn’t want to pay for experimental / unproven treatments for patients even if there are few or no alternatives for treatment.  He is hoping to appeal this regulation so that he can continue his research since there is such a high rate of mesothelioma, that disproportionately affects rural Turkish patients.

 The University of Gaziantep Hospital

The University of Gaziantep Hospital

The University Hospital is one of several hospitals in Gaziantep.  The academic institution has over 900 beds and 20 operating rooms spread out over three floors.  There is a large 24 bed surgical ICU which includes 4 dedicated thoracic surgery beds.

Thoracic surgery may not be the advertised superstar of the hospital but it is the backbone of patient care.  There are three full-time professors of surgery; Dr. Ahmet Isik, Dr. Levent Elbeyli and Dr. Bulent Tunçözgür, along with an associate professor, Dr. Maruf Sanli, several thoracic surgery fellows and research assistants.  Together the thoracic surgery team performs over 1000 cases a year.

Dr. Levent Elbeyli is the driving force for thoracic surgery.  A Gaziantep native, he founded the department in 1992, and has seen it grow from a few scattered beds to a full-fledged program with a full-time clinic, 2 dedicated operating rooms, 4 ICU beds and 15 to 20 cases a week.

Dr. Levent Elbeyli (in loupes) in the operating room
Dr. Levent Elbeyli (in loupes) in the operating room

For the thoracic nurse, the department of Thoracic Surgery is a dream come true; tracheal cases, surgical resections, esophagectomies, thoracic trauma – all of the bread and butter that makes our hearts go pitter-pat.  But then there is also plenty of pediatric cases, pectus repair, foreign body removal (oro-esophageal) and on-going surgical research.  They do a large amount of pediatric and infant bronchoscopies (for foreign body obstructions, tracheal malformations etc).

There is the slightly exotic hydatid cysts and the more mundane (but my personal favorite) empyema thoracis to be treated.  Cancers to be staged, and chest wall resections to undertake.  I feel almost overwhelmed in my own petite version of a candy store; everywhere I turn I see opportunities to learn, case reports to write and new things to see.

Dr. Levent Elbeyli operates as Dr. Isik observes.
Dr. Levent Elbeyli operates as Dr. Isik observes.

My non-medical readers might be slightly repulsed by my glee – but it is this intellectual interest that keeps me captivated, engaged and enamored with thoracic surgery and caring for thoracic surgery patients.   And then there is the HITHOC program.  With a large volume of mesothelioma and pleural based cancers due to endemic environmental asbestos in rural regions of Turkey, there is an opportunity to bring hope and alleviate suffering on a larger level.  (Dr. Isik sees more cases here in his clinic in one year than I have seen in my entire career).

What’s not to love about that?

Article updates:

Since our original visit to Dr. Isik, he has continued his work on HITHOC for malignant pleural mesothelioma and other cancers.  You can read his latest paper, “Can hyperthermic intrathoracic perfusion chemotherapy added to lung sparing surgery be the solution for malignant pleural mesothelioma?

In this study, Dr. Isik and hs team looked at 73 patients with malignant pleural mesothelioma (MPM) who were in three different treatment groups.  Group 1 received surgery only (extrapleural pneumonectomy).  Group 2 received palliative treatment only.  Group 3 received lung sparing surgery with hyperthermic chemotherapy (HITHOC).  Lung sparing surgery included pleural decortication.

While the treatment groups are small, the results show a clear survival benefit to the patients receiving HITHOC.   Surprisingly, the palliative group lived longer than the surgery alone group.

Survival based on treatment modality:

Surgery only:  5 months average surgery.  15% survival at 2 years

Palliative treatment only: 6 months average survival   17.6% at 2 years

HITHOC group:  27 months average survival    56.5% at 2 years

Selected Bibliography for Dr. Işık  

Işık AF, Sanlı M, Yılmaz M, Meteroğlu F, Dikensoy O, Sevinç A, Camcı C, Tunçözgür B, Elbeyli L (2013). Intrapleural hyperthermic perfusion chemotherapy in subjects with metastatic pleural malignancies. Respir Med. 2013 May;107(5):762-7. doi: 10.1016/j.rmed.2013.01.010. Epub 2013 Feb 23. The article that brought me to Turkey, and part of our series of articles on the evolving research behind HITHOC.

Isik AF, Tuncozgur B, Elbeyli L, Akar E. (2007).  Congenital chest wall deformities: a modified surgical technique.  Acta Chir Belg. 2007 Jun;107(3):313-6.

Isik AF, Ozturk G, Ugras S, Karaayvaz M. (2005).  Enzymatic dissection for palliative treatment of esophageal carcinoma: an experimental study.  Interact Cardiovasc Thorac Surg. 2005 Apr;4(2):140-2. Epub 2005 Feb 16.

Er M, Işik AF, Kurnaz M, Cobanoğlu U, Sağay S, Yalçinkaya I. (2003).  Clinical results of four hundred and twenty-four cases with chest trauma. Ulus Travma Acil Cerrahi Derg. 2003 Oct;9(4):267-74. Turkish.

Sanli M, Arslan E, Isik AF, Tuncozgur B, Elbeyli L. (2013). Carinal sleeve pneumonectomy for lung cancer. Acta Chir Belg. 2013 Jul-Aug;113(4):258-62.

Maruf Şanlı, MD, Ahmet Feridun Isik, MD, Sabri Zincirkeser, MD, Osman Elbek, MD, Ahmet Mete, MD, Bulent Tuncozgur, MD and Levent Elbeyli, MD (2008). Reliability of positron emission tomography–computed tomography in identification of mediastinal lymph node status in patients with non–small cell lung cancer. The Journal of Thoracic and Cardiovascular Surgery, Volume 138, Issue 5, Pages 1200–1205, November 2009.

Sanlı M, Isik AF, Tuncozgur B, Elbeyli L. (2009).  A new method in thoracoscopic inferior mediastinal lymph node biopsy: a case report.  J Med Case Rep. 2009 Nov 3;3:96. doi: 10.1186/1752-1947-3-96.

Sanli M, Isik AF, Zincirkeser S, Elbek O, Mete A, Tuncozgur B, Elbeyli L. (2009).  The reliability of mediastinoscopic frozen sections in deciding on oncological surgery in bronchogenic carcinoma. J Thorac Cardiovasc Surg. 2009 Nov;138(5):1200-5. doi: 10.1016/j.jtcvs.2009.03.035. Epub 2009 Jun 18.

Sanli M, Işik AF, Tunçözgür B, Arslan E, Elbeyli L. (2009).  Resection via median sternotomy in patients with lung cancer invading the main pulmonary artery.  Acta Chir Belg. 2009 Jul-Aug;109(4):484-8.

Sanli M, Isik AF, Tuncozgur B, Elbeyli L.  (2010).  Successful repair in a child with traumatic complex bronchial rupture.  Pediatr Int. 2010 Feb;52(1):e26-8. doi: 10.1111/j.1442-200X.2009.03000.x

Sanli M, Işik AF, Tunçözgür B, Meteroğlu F, Elbeyli L. (2009).  Diagnosis that should be remembered during evaluation of trauma patients: diaphragmatic rupture].  Ulus Travma Acil Cerrahi Derg. 2009 Jan;15(1):71-6. Turkish.

Thoracic surgery shortage worsens as graduates fail to pass exams

a record number of surgeons fail to pass the American thoracic surgery certification exam, in the midst of a deepening shortage of surgeons.

A new report from the (American) Board of Thoracic Surgery shows a growing number of eligible surgeons are failing the thoracic surgery certification examination.

Record Failure Rate

As stated in the article published at Family Practice News, the failure rate has doubled to 28% in just a few short years.  This comes at a critical period in American medicine as shortages in specialty surgeons have emerged around the country due to an aging workforce.  This shortage is not confined to the United States – and has been echoed in Canada, the UK and several other industrialized nations.

Decrease in resident hours = decreased surgical knowledge

This record failure rate comes in the wake of recent reforms to resident surgical education  – including several reductions in resident training hours, and the push for a condensed 6 year residency program.

Rapidly evolving surgical technology

At the same time, rapidly evolving surgical technology and research in thoracic surgery may actually require significant curriculum changes and increased length of specialty training, according to this report at Thoracic Surgery News.

But, as previously reported, the extensive training requirements for cardiothoracic surgery have led to fewer residents and widespread vacancies in residency programs as fewer and fewer surgical residents elect to devote themselves to cardiothoracic surgery due to concerns about diminishing financial returns, reduced economic opportunities, excessive student loan burdens and concerns related to the hardships of the ‘cardiothoracic lifestyle’.

Solo Cardiac, General Thoracic tracks may trump combined “Cardiothoracic”

Alternatively, North American surgeons may need to follow the example of many of their international peers and diverge into two separate tracks: cardiac surgery and general thoracic to maintain surgical proficiency without excessive education burden in an era of rapidly evolving surgical knowledge.

 

Additional Recommended Reading:

Ann Thorac Surg. 2009 Aug;88(2):515-21; discussion 521-2. doi: 10.1016/j.athoracsur.2009.04.010.

Extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma revisited: the Australian experience

A discussion of and link to the Yan et. al (2011) article, “Improving survival rates after surgical management of pleural malignant mesothelioma: an australian institutional experience” as part of a series of posts on mesothelioma and extrapleural pneumonectomy (EPP).

A recent study by Yan et al. (2011) conducted at the Royal Prince Alfred Hospital in Sydney, Australia does more than look at the outcomes of the aforementioned treatment for malignant pleural mesothelioma.  This study, involving 540 patients, over 25 years also gives us a primer on the evolving treatment therapies for this condition.  As newer treatment therapies emerged, these therapies were given to eligible patients, starting with extrapleural pneumonectomy itself, in 1994 and extending to include both radiotherapy and chemotherapy. Chemotherapy consisted of a combination of pemtrexed, carboplatin and cisplatin.  While this alters the results significantly it also provides for an interesting introspective on the treatment of malignant pleural mesothelioma.

This study is noteworthy for both this reason, and as a study looking at a larger set of patients than many of the other studies on this topic.

Study Design: consecutive, non-randomized.

Patient population:  540 patients; organized into two groups for statistical analysis.  Group I – 270 patients (consecutive patients from March 1984 to September 1999.)  Group II – consecutive patients September 1999 to Jan 2008.  As the authors noted, due to the rarity of this condition in Australia, it took 25 years to recruit 540 patients for treatment.

Patient characteristics: the vast majority were male (455 patients)  with a mean age of 66 (+/- 11 years).  315 patients with right-sided disease, the remaining 225 with left-sided disease.

Disease subtypes:

235 patients with epithelial subtype, 212 with sarcomoid/ biphasic  (type determined by tissue pathology)

Treatments received:

69 patients had extrapleural pneumonectomy

269 patients received pleurectomy/ decortication

202 patients received pleurodesis

62 patients received post-operative radiotherapy starting 8 to 12 weeks after surgery. This treatment was added in 2002.

65 of the patients received adjunctive chemotherapy

Notably, as mentioned above, there was a distinct difference in the treatment allocation for groups I and II due to changing treatment protocols, and the development of new therapies.  While 22% of patients in group II received EPP, only 5% of patients in group I received the same surgical procedure.

Treatment strategies were also limited by patient factors; namely the patient’s physical condition / functional status as being considered able to withstand the proposed treatment therapy.  As mentioned in a previous post, extrapleural pneumonectomy is an extensive surgical procedure which requires significant patient reserves and pre-existing functional abilities for anticipated recovery.  In frail or debilitated patients, (as defined by criteria set forth by Yan et. al) EPP was not attempted.  Some of these patients received either pleurectomy with decortication.  In patients deemed too fragile to withstand either of these procedures, a talc pleurodesis (either by VATS or tube thoracostomy) was performed as a palliative procedure.  Unsurprisingly, the patients receiving palliative treatment options had shorter median survival periods.

Results:

18 patients died in the perioperative period, including 3 EPP patients.

Median follow-up period for the study was ten months.  At the time of follow-up the majority of patients (433 patients, 80%) had died with a median survival time of nine months for group I (range 0 – 115 months).

In group II, the median survival time was 13 months.  (range 0 – 72 months).

Long term survival by group:

Group   I                                                  Group II

1 year      35%                                                     50 %

2 year     16%                                                     22%

3 year       9 %                                                      12%

5 year        2 %                                                       9 %

These five-year survival rates highlight the importance of continued studies for the advancement of treatment therapies for this condition.

Factors associated with greater survival:

In reviewing their research, the authors were able to identify four independent factors that increased the likelihood of survival in this population. (See original article for discussion in further depth.)

1. Yan et. al found that the epithelial subtype was more favorable for patient survival, and that this subtype was more common in the patients in group II.

2.  The surgeon’s experience (of greater than 100 cases) was positively correlated with greater survival.  Surgeon expertise has been shown to be a factor for better patient outcomes in multiple procedures.

3. Patients who received EPP had improved survival compared to patients who received other treatments.  However, this also reflects a selection bias, since the patients who were eligible for EPP had better pre-operative functional status than patients who received other treatments.

4.  Premetrexed chemotherapy – patients who received this chemotherapy regimen had greater survival.

blog author’s note:

Despite dismal five year survival rates for treatment of malignant pleural mesothelioma by a multitude of treatment methods, extrapleural pneumonectomy (with adjuvant chemotherapy) appears to be the most effective cytoreductive surgery for this condition. ( As noted in related posts, HITHOC is an emerging therapy that combines the principles of both.) We will continue to follow research in these areas for the treatment of malignant pleural mesothelioma and invite the experts to add their comments.

Original article:   Yan, T. (2011). Improving survival rates after surgical management of malignant pleural mesothelioma: an australian institutional experienceAnn Thorac Cardiovasc Surg 2011; 17: 243-249.  Primary author: Dr. Tristan Yan.

Latest research findings: Mesothelioma

new research results from the University of Pennsylvania on the treatment of pleural mesothelioma.

The University of Pennsylvania reports the latest results of a small study involving 28 patients with pleural mesothelioma.

This limited study compared combination treatment using photodynamic therapy along with a lesser lung surgery (14 patients) in comparison to extrapleural pneumonectomy alone (14 patients).  22 of the 28 patients also received chemotherapy.

Patient population: 28 patients – 12 /14 patients in either group with advanced (stage III/IV ) disease

Results:  Extrapleural pneumonectomy group had a median survival of 8.9 months.  The combination photodynamic/ surgery group median survival exceeded two years (when the study ended).

Take away message for readers:  It’s too early, and the study groups are far too small for us to generalize these findings.  However, these preliminary results are encouraging and should prompt more, larger scale studies / trials looking at photodynamic therapy as adjuvant therapy along with thoracic surgery for pleural mesothelioma.

 

Update: 06/15/2011:

the mesothelioma study from PA just got picked up by a major wire service, so expect to read and hear a lot more about it.

Update: 08/15/2014:  Mesothelioma.net has asked that I link with their site.  They offer some informational services for people facing mesothelioma.  Please let me know if this site is spam-plagued or otherwise dubious and I will remove the link (the site is a bit ‘shiny’ and circular for my taste.)

Extrapleural Pneumonectomy: EPP

Extrapleural pneumonectomy for malignant mesothelioma

Extrapleural Pneumonectomy (EPP) is a radical operation in which the entire lung, and tissues of the lung space (pleura, diaphragm and pericardium) are removed.  This is done as part of a cancer operation, often for an aggressive cancer called malignant mesothelioma. During cancer operations, surgeons have to remove all or as much cancer tissue as possible, including microscopic cells that are not visible to the surgeon at the time of surgery.  Any tissue that is left behind may have cancer cells which will continue to grow, and spread.  Due to the location of the cancer cells (in the lining), surgeons have to remove more tissue than if the cancer was centered in the lung itself.  This includes replacing the diaphragm with a synthetic patch during surgery.

Mesothelioma is named after the cells it affects.  These mesothelial cells make up the “linings” of the body cavities.  For this reason, mesothelioma can affect other areas of the body, in the linings of the abdomen called the peritoneum, the pericardium (the lining around the heart), and most commonly, the pleura.

Inside the chest, coating the chest wall is a thin lining tissue called the pleura.  The interior area of the rib cage and chest are thus called the pleural cavity.  When mesothelial cancer cells invade this fragile tissue layer, it is called pleural mesothelioma, which is different from peritoneal mesothelioma.  (Peritoneal mesothelioma affects the peritoneal cavity, or abdominal cavity.)

Not everyone is a candidate for this surgery.  Due to the radical nature of this procedure, patients need to have good pulmonary function and overall functional status prior to surgery.  (The patient is going to lose one whole lung during this procedure, so patients that are already oxygen dependent / bedridden or otherwise debilitated won’t be able to tolerate this procedure.)  The best patients for this surgery (the patients who will have the best outcomes/ receive the most benefits from surgery) are patients with good functional status (able to perform normal activities of daily living) with earlier stages of the disease.  In these patients – this surgery can extend their lives significantly.  In patients with more advanced (stage III/ stage IV) disease, the surgery will make them live longer (months) but the quality of life may be worse post-operatively.

Prior to consideration for extrapleural pneumonectomy (or any other treatment) the doctors will want to definitively diagnose (prove the diagnosis through tissue biopsy) and do preliminary staging.  (Final staging occurs after the operation when further tissue / lymph node biopsies are evaluated by the pathologist).

Preliminary staging and pre-operative evaluation is the process to try to figure out how much cancer is present (has it spread?) and whether the patient can tolerate a large operation.  Mediastinoscopy; a surgical procedure to look at mediastinal lymph nodes (lymph nodes behind the sternum or breast bone), PET scans and blood for tumor markers help determine how much cancer is present.  The tumor markers also help the oncologists figure out which chemotherapy drugs will work the best.

Pre-operative testing is looking at lung function, to see how well the patient will do with only one lung.  Cardiac testing may be done as well since surgery can be stressful to the heart.

If the disease is controllable with surgery, and the surgeon thinks the patient can withstand surgery – the surgeon will consult with an oncologist about the timing of surgery and adjuvant treatments (chemotherapy/ radiation).

Even with radical surgery, the prognosis for malignant pleural mesothelioma is poor, but improves with combination therapies (surgery with chemotherapy/ radiation.)  Currently, surgeons are investigating the use of cytoreductive hyperthermic chemotherapy  (HIPEC/ Hithoc) for treatment of pleural based mesothelioma.  (Previous studies by Dr. Paul Sugarbaker has shown this treatment to be effective with advanced abdominal cancers including malignant peritoneal mesothelioma.)  We will discuss HIPEC further on a future post.

There are numerous studies looking at extrapleural pneumonectomy for treatment of malignant pleural mesothelioma. The links below is just a small sampling.

1. Extrapleural pneumonectomy for malignant pleural mesothelioma (2005) – Argote- Greene, Chang, and Sugarbaker. (Note: this article was co-authored by Dr. David Sugarbaker, Department of Thoracic surgery, Brigham Womens & Children’s, not Dr. Paul Sugarbaker, developer of HIPEC.  I am going to attempt to contact Dr. Davis Sugarbaker for commentary for the site since he is the expert on this topic, so hopefully I’ll be able to update the site with his post in the future.

2.  Radical surgery for malignant pleural mesothelioma – Japanese study comparing results for EPP versus pleurectomy / decortication.  The main points to take away from this study is that stage of disease has a huge impact on prognosis, and outcomes after surgery.  (The patients with stage I and II that underwent EPP did fairly well.)

3. Review of 83 cases of EPP – (2009) French study which unintentionally highlights the potential complications of surgery of this magnitude(almost 40% had major complications and had a re-operative rate of almost fifteen percent.)