A systematic review of extrapleural pneumonectomy for malignant pleural mesothelioma

Our plain-English summary of A systematic review of extrapleural pneumonectomy for malignant pleural mesothelioma, by C.Q. Cao, T.D. Yan, P.G. Bannon, et al (Journal of Thoracic Oncology, 2010).

The study

• Authors: C.Q. Cao, T.D. Yan, P.G. Bannon, B.C. McCaughan
• Journal: Journal of Thoracic Oncology
• Published: 2010;5(10):1692-703
• Type of article: Systematic review
• Cited by: 104 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: The primary objective of the present systematic review was to evaluate the safety and efficacy of extrapleural pneumonectomy (EPP) for patients with malignant pleural mesothelioma.

Methods: A systematic review of relevant studies identified through five online search databases was performed. Two reviewers independently appraised each study.

Results: Thirty-four of 58 relevant studies from 26 institutions containing the most updated data were evaluated for survival and perioperative outcomes after EPP. The median overall survival varied from 9.4 to 27.5 months, and 1-, 2-, and 5-year survival rates ranged from 36 to 83%, 5 to 59%, and 0 to 24%, respectively. Overall perioperative mortality rates ranged from 0 to 11.8%, and the perioperative morbidity rates ranged from 22 to 82%. Quality of life assessments from three studies reported improvements in nearly all domains at 3 months postoperatively. Patients who underwent trimodality therapy involving EPP and adjuvant chemoradiotherapy had a median overall survival of 13 to 23.9 months.

Discussions: The current evidence suggests that selected patients with malignant pleural mesothelioma may benefit from EPP, especially when combined with neoadjuvant or adjuvant chemotherapy and adjuvant radiotherapy.

In plain English

In this systematic review, the authors searched five databases (January 1985 to January 2010) for published studies of patients with malignant pleural mesothelioma treated by extrapleural pneumonectomy (EPP). EPP is an operation removing the lung, the chest lining, the diaphragm and the pericardium on one side. Of 58 eligible studies covering 3749 patients, 34 studies from 26 institutions (2462 patients) were analysed. Across these studies, median overall survival ranged from 9.4 to 27.5 months, and 5-year survival ranged from 0 to 24%. Deaths around the time of surgery ranged from 0 to 11.8%, and complication rates ranged from 22 to 82%. Three quality-of-life studies, two of them on the same patients, found improvement in nearly all areas by 3 months after surgery. Some studies combined EPP with chemotherapy and radiotherapy. When chemotherapy followed surgery, median survival ranged from 13 to 23.9 months. When it preceded surgery, median survival among all patients intended for treatment ranged from 14 to 25.5 months. The authors concluded that selected patients may benefit from EPP, especially combined with chemotherapy and radiotherapy. They cautioned that the studies differed widely and that no randomized trial had been completed.

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 of published studies of extrapleural pneumonectomy; two reviewers independently appraised each study
• Who was studied: Published studies (searched January 1985 to January 2010) of patients with histologically proven malignant pleural mesothelioma treated by EPP. 58 studies covering 3749 patients were identified; 34 studies from 26 institutions, with 2462 patients, were included in the final evaluation
• Exposure: No asbestos exposure was studied. The treatment reviewed was extrapleural pneumonectomy, alone or combined with chemotherapy, radiotherapy, intrapleural chemotherapy or photodynamic therapy
• Main results:
  • Across the included studies, median overall survival after EPP ranged from 9.4 to 27.5 months
  • Across the included studies, 1-, 2-, 3- and 5-year survival rates ranged from 36 to 83%, 5 to 59%, 0 to 41% and 0 to 24%
  • Perioperative mortality across studies ranged from 0 to 11.8%; in the middle two quartiles of studies it was 3.7% to 7.6%
  • Overall perioperative complication (morbidity) rates ranged from 22 to 82%, and major morbidity from 12.5 to 48%
  • Three quality-of-life studies (two on the same set of trimodality patients) found improvements in nearly all domains at 3 months after surgery
  • In trimodality therapy with EPP plus adjuvant chemoradiotherapy, perioperative mortality ranged from 0 to 11% and median overall survival from 13 to 23.9 months
  • In trimodality therapy with chemotherapy before EPP, 50 to 71% of intention-to-treat patients completed the planned regimen. Perioperative mortality ranged from 0 to 6.7%, and median overall survival for the intention-to-treat population ranged from 14 to 25.5 months
• The authors' conclusion: The authors concluded that the current evidence suggests selected patients with malignant pleural mesothelioma may benefit from EPP, especially when combined with neoadjuvant or adjuvant chemotherapy and adjuvant radiotherapy
• Limitations the authors state:
  • The studies differed considerably in patient selection, treatment regimens, follow-up methods and how survival was calculated
  • Some studies counted survival from diagnosis or start of chemotherapy rather than surgery, which gives longer survival figures
  • Patients whose disease progressed on chemotherapy before surgery were often excluded from EPP, so better survival may reflect selection of less aggressive disease
  • Follow-up varied greatly, so recurrence and disease-free survival figures should be interpreted cautiously
  • No randomized controlled trial of EPP had been completed

Topics

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

Medical terms in this study, explained in our Lexicon: Systematic Review, Extrapleural Pneumonectomy (EPP), Pleural Mesothelioma, Median Overall Survival, Quality of Life, Trimodality Therapy, Chemotherapy.

Related studies

• Extrapleural pneumonectomy for malignant pleural mesothelioma: outcomes of treatment and prognostic factors — T.D. Yan, M. Boyer, et al. (2009)
• Summary of prognostic factors and patient selection for extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma — C. Cao, T.D. Yan, et al. (2011)
• Staging of patients after extrapleural pneumonectomy for malignant pleural mesothelioma--institutional review and current update — C. Cao, S.K. Krog Andvik, et al. (2011)
• Low calretinin expression and high neutrophil-to-lymphocyte ratio are poor prognostic factors in patients with malignant mesothelioma undergoing extrapleural pneumonectomy — S.C. Kao, S. Klebe, et al. (2011)
• Extrapleural pneumonectomy in the treatment of epithelioid malignant pleural mesothelioma: novel prognostic implications of combined N1 and N2 nodal involvement based on experience in 529 patients — D.J. Sugarbaker, W.G. Richards, et al. (2014)
• Epithelial malignant pleural mesothelioma after extrapleural pneumonectomy: stratification of survival with CT-derived tumor volume — R.R. Gill, W.G. Richards, et al. (2012)

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