“Lower door open thoracotomy”: a feasible approach for extra-pleural pneumonectomy

We read with great interest the article by Bedirhan et al. (1) reporting on a series of 76 patients undergoing surgical treatment for malignant pleural mesothelioma (MPM). Nowadays, although different therapeutic options are available (chemotherapy, radiotherapy, surgery, photodynamic, immune- and gene therapy), a definitive treatment for patients affected by MPM remains controversial (2). As well, in order to compare different surgical strategies, randomized clinical trials with a large number of patients are hardly feasible due to high morbidity rate related to each surgical procedure (3). To date, radical surgery with extra-pleural pneumonectomy (EPP) and adjuvant treatments has become the preferred option in early disease, but the benefits of such an aggressive approach have been discussed because of significant treatment-related morbidity and mortality (4).