A systematic review of lung-sparing extirpative surgery for pleural mesothelioma

Our plain-English summary of A systematic review of lung-sparing extirpative surgery for pleural mesothelioma, by E. Teh, F. Fiorentino, C. Tan, et al (Journal of the Royal Society of Medicine, 2011).

The study

• Authors: E. Teh, F. Fiorentino, C. Tan, T. Treasure
• Journal: Journal of the Royal Society of Medicine
• Published: 2011;104(2):69-80
• Type of article: Systematic review
• Cited by: 27 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Objectives: There is a resurgence of interest in lung-sparing extirpative surgery for malignant pleural mesothelioma with recent reports of better survival and fewer adverse consequences than with extrapleural pneumonectomy. However, these operations are not well-characterized and to offer evidence-based clinical recommendations and to plan future trials a summary of what is already known is required.

Design: A formal literature search was performed and all recovered titles were sequentially sifted by title, abstract and full-text reading according to prespecified criteria. Papers were selected if they contained data relevant to the area of enquiry. Quantitative synthesis and textual analysis, appropriate to the material, were performed.

Setting: Follow-up studies of patients undergoing surgery for malignant pleural mesothelioma in specialist thoracic or cardiothoracic units.

Participants: Among the operated patients described in these papers, a total of 1270 patients had undergone lung-sparing surgery for mesothelioma.

Results: There were no randomized trials or other forms of controlled studies. From 464 titles, 26 papers contained sufficient data on 1270 patients to be included in the systematic review. Operative descriptions for all series were extracted and tabulated and variation was found in the nature of surgery within and between series, and the degree of detail with which it was described. There was more operative detail in recent papers. All available numerical data were extracted, tabulated and summarized using quantitative methods. The average survival at 1, 2, 3, 4 and 5 years was 51%, 26%, 16%, 11% and 9%, respectively. There were no data on patients' performance status, symptomatic change, or other patient reported outcomes.

Conclusions: In the absence of any form of control data, no conclusions can be drawn concerning survival differences or symptomatic benefits attributable to surgery. As mesothelioma surgery is restricted to a selected minority of patients who often have multiple therapies, future research will require controlled studies with explicit definitions of the clinical and surgical intent.

In plain English

This was a systematic review of published reports on lung-sparing surgery for malignant pleural mesothelioma, meaning operations such as pleurectomy/decortication that remove tumour but not the lung. From 464 titles, the authors included 26 papers with usable data on 1270 operated patients. None of the included studies were randomized trials, and none compared operated patients with a non-operated control group. Weighted mean age was 62 years, and on average 80% were men. Asbestos exposure was recorded in 13 papers and was positive in 64% of patients (682 of 1061), although some reports gave this rate for all mesothelioma patients, not only operated ones. The operations varied considerably within and between series. Average survival at 1, 2, 3, 4 and 5 years was 51%, 26%, 16%, 11% and 9%. There were no data on performance status, symptom change or other patient-reported outcomes. The authors had no patient-level data and described their analyses as illustrative. They concluded that, without control data, no conclusions could be drawn about survival differences or symptom benefits attributable to surgery.

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 follow-up studies (case series) of lung-sparing surgery for malignant pleural mesothelioma, with quantitative synthesis and textual analysis
• Who was studied: 26 published papers reporting 1270 patients who had lung-sparing surgery for malignant pleural mesothelioma in specialist thoracic or cardiothoracic units. The series covered operations from 1958 to 2006, which the authors describe as about 50 years of surgery. The weighted mean age was 62 years and on average 80% were men.
• Exposure: The treatment studied was lung-sparing extirpative surgery (pleurectomy/decortication and related operations such as partial, total, radical or non-radical pleurectomy and debulking), which does not include pneumonectomy. Asbestos exposure was recorded in 13 papers and was positive in 64% of patients (682/1061), with a range of 17–95%. In some reports this rate applied to all mesothelioma patients, not only those operated on. No fiber types are given.
• Main results:
  • No randomized trials were found, and no studies compared surgery outcomes with a non-operated control group.
  • Across the included series, average survival after lung-sparing surgery at 1, 2, 3, 4 and 5 years was 51%, 26%, 16%, 11% and 9%.
  • The weighted mean age of operated patients was 62 years, and on average 80% were men.
  • The surgery performed varied considerably between and within series, and descriptions became more detailed in recent papers.
  • Six larger series (more than 50 or more than 100 cases) had median survivals of 10–15 months.
  • The included papers gave no data on performance status, symptom change or other patient-reported outcomes.
• The authors' conclusion: The authors concluded that, without any control data, no conclusions can be drawn about survival differences or symptom benefits attributable to surgery. They said future research will require controlled studies with explicit definitions of clinical and surgical intent.
• Limitations the authors state:
  • The authors had no patient-level data, and their analyses are illustrative rather than definitive.
  • Different types of patients were likely deliberately selected for lung-sparing surgery versus extrapleural pneumonectomy, which limits further analysis.
  • Any apparent longer survival in recent series may reflect lead time bias, stage migration or reporting bias, so it cannot reliably be credited to newer techniques.
  • Adjuvant therapies varied widely and were not described well enough to analyse.
  • Asbestos exposure rates in some reports covered all mesothelioma patients, not only those operated on.

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, Pleural Mesothelioma, Extrapleural Pneumonectomy (EPP), Mesothelioma, Performance Status.

Related studies

• Changes in lung function after surgery for mesothelioma — T. Ploenes, T. Osei-Agyemang, et al. (2013)
• National Cancer Database Report on Pneumonectomy Versus Lung-Sparing Surgery for Malignant Pleural Mesothelioma — V. Verma, C.A. Ahern, et al. (2017)
• Photodynamic therapy and the evolution of a lung-sparing surgical treatment for mesothelioma — J.S. Friedberg, R. Mick, et al. (2011)
• A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma — C. Cao, D. Tian, et al. (2014)
• The new case for cervical mediastinoscopy in selection for radical surgery for malignant pleural mesothelioma — A. Nakas, D. Waller, et al. (2012)
• The management of the diaphragm during radical surgery for malignant pleural mesothelioma — A.J. Sharkey, R. Bilancia, et al. (2016)

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