A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma

Our plain-English summary of A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma, by C. Cao, D. Tian, J. Park, et al (Lung Cancer, 2014).

The study

• Authors: C. Cao, D. Tian, J. Park, J. Allan, K.A. Pataky, T.D. Yan
• Journal: Lung Cancer
• Published: 2014;83(2):240-5
• Type of article: Meta-analysis, Systematic review
• Cited by: 196 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Malignant pleural mesothelioma (MPM) is an aggressive disease of the pleural lining with a dismal prognosis. Surgical treatments of MPM with a curative intent include extrapleural pneumonectomy and extended pleurectomy/decortication (P/D). This meta-analysis aimed to compare the perioperative and long-term outcomes of EPP and extended P/D for selected surgical candidates.

Methods: A systematic review of the literature was performed on six electronic databases to identify all relevant data on comparative outcomes of extended P/D and EPP in a multimodality setting. Endpoints included perioperative mortality and morbidity, as well as long-term overall survival.

Results: Seven relevant studies with comparative data on EPP (n=632) versus extended P/D (n=513) were identified from the current literature. Comparison of these two groups demonstrated significantly lower perioperative mortality (2.9% vs. 6.8%, p=0.02) and morbidity (27.9% vs. 62.0%, p<0.0001) for patients who underwent extended P/D compared to EPP. Median overall survival ranged between 13-29 months for extended P/D and 12-22 months for EPP, with a trend favouring extended P/D.

Conclusions: Although it must be emphasized that patient selection and treatment strategies differ between EPP and extended P/D, a number of comparative studies have recently been conducted to compare these two surgical techniques for patients with resectable MPM. The present study indicated that selected patients who underwent extended P/D had lower perioperative morbidity and mortality with similar, if not superior, long-term survival compared to EPP, in the context of multi-modality therapy. This may represent an important paradigm shift in the surgical management of MPM.

Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

In plain English

This systematic review and meta-analysis compared two operations for malignant pleural mesothelioma. Extrapleural pneumonectomy (EPP) removes the pleura, the lung, and the diaphragm and pericardium on that side. Extended pleurectomy/decortication (extended P/D) removes the pleura and all visible tumour, taking the diaphragm and/or pericardium as required. The authors searched databases up to September 2013 and found seven observational studies covering 1145 patients: 632 had EPP and 513 had extended P/D. Deaths around the time of surgery were 2.9% after extended P/D and 6.8% after EPP. Complications were 27.9% and 62.0%. Both differences were statistically significant. There were not enough data to combine survival results. Median survival ranged from 13 to 29 months with extended P/D and 12 to 22 months with EPP; four studies counted survival from surgery, three from diagnosis. The authors concluded that extended P/D could be done with lower complication and death rates and comparable survival, but stressed that patient selection differed between the operations. They noted that all included studies were retrospective and that definitions varied between centres. The article did not examine asbestos exposure.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Systematic review and meta-analysis of comparative studies; all seven included studies were observational
• Who was studied: Seven observational studies identified in databases searched from their inception to September 2013. Together they covered 1145 patients with malignant pleural mesothelioma (MPM): 632 who underwent EPP and 513 who underwent extended P/D. Per Table 1, the studies came from Turkey, the UK, Italy, the USA, Japan and Germany, with study periods between 1986 and 2013 where reported.
• Exposure: Not an asbestos exposure study. What was compared was surgical treatment: extrapleural pneumonectomy (EPP) versus extended pleurectomy/decortication (extended P/D), often combined with chemotherapy, radiotherapy or other added therapies.
• Main results:
  • All-cause perioperative mortality was significantly lower after extended P/D than after EPP: 2.9% versus 6.8%, relative risk 0.53 (95% CI 0.31 to 0.91), P = 0.02, I2 = 0%.
  • Perioperative morbidity (complications) was significantly lower after extended P/D than after EPP: 27.9% versus 62.0%, relative risk 0.44 (95% CI 0.30 to 0.63), P less than 0.0001, I2 = 44%.
  • There were insufficient data to meta-analyse overall survival.
  • Median overall survival ranged from 13 to 29 months for patients treated with extended P/D and 12 to 22 months for patients treated with EPP, with a trend favouring extended P/D. This range is stated in the article's abstract.
  • Survival was measured from the date of surgery in 4 studies and from the date of diagnosis in 3 studies.
• The authors' conclusion: The authors concluded that extended P/D can be performed with lower morbidity and mortality and comparable long-term survival to EPP. They emphasised that patient selection and treatment strategies differ between the two operations, and that the procedures are not interchangeable for all patients.
• Limitations the authors state:
  • Endpoints were defined differently across institutions, and classification of perioperative morbidity varied significantly.
  • Survival was measured from the date of surgery in some studies and from the date of diagnosis in others, which can lengthen apparent survival (lead time bias).
  • All included studies were retrospective observational studies, so baseline patient characteristics may have differed between treatment groups.
  • Analyses accounting for confounding factors were not possible because raw data were not available.
  • The retrospective classification of procedures as extended P/D may not have been precise for all patients.
  • Patient selection and treatment strategies differed between EPP and extended P/D.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Systematic Review, Meta-Analysis, Pleural Mesothelioma, Prognosis, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D), Overall Survival, Median Overall Survival.

Related studies

• Photodynamic therapy and the evolution of a lung-sparing surgical treatment for mesothelioma — J.S. Friedberg, R. Mick, et al. (2011)
• Systematic review of pleurectomy in the treatment of malignant pleural mesothelioma — C. Cao, D.H. Tian, et al. (2013)
• Meta-Analysis of Different Procedures: The Importance of Recognizing the Spectrum of Pleurectomy/Decortication Techniques — C. Cao, D.H. Tian, et al. (2015)
• Surgery as part of radical treatment for malignant pleural mesothelioma — D.A. Waller, S. Tenconi (2017)
• Current surgical strategies for malignant pleural mesothelioma — T. Takuwa, S. Hasegawa (2016)
• A systematic review and meta-analysis of second-line therapies for treatment of mesothelioma — F. Petrelli, R. Ardito, et al. (2018)

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