Clinical impact of extrapleural pneumonectomy for malignant pleural mesothelioma

Our plain-English summary of Clinical impact of extrapleural pneumonectomy for malignant pleural mesothelioma, by V. Ambrogi, A. Baldi, O. Schillaci, et al (Annals of Surgical Oncology, 2012).

The study

• Authors: V. Ambrogi, A. Baldi, O. Schillaci, T.C. Mineo
• Journal: Annals of Surgical Oncology
• Published: 2012;19(5):1692-9
• Cited by: 21 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: The clinical impact of extrapleural pneumonectomy in malignant pleural mesothelioma is poorly investigated.

Methods: Between 1997 and 2007, 29 consecutive patients underwent extrapleural pneumonectomy for mesothelioma and adjuvant chemoradiotherapy. Function (spirometry, arterial blood gas analysis, 6-min walk test, and echocardiographic fraction ejection estimation), symptoms (quantification of pain, dyspnea, cough, fever, weight loss, and Karnofsky performance status) and quality of life [Medical Outcomes Study Short Form, 36 item (SF-36) and St. George's Respiratory Questionnaire] were timely evaluated. Data were prospectively collected and retrospectively reviewed.

Results: Only one postoperative death occurred. 30-day postoperative morbidity was 41%. Median survival was 19.5 months with 17 patients still alive at 1 year and 10 at 2 years, respectively. At 3 months, the expected decrement of forced expiratory volume in 1 s (P = 0.06) and forced vital capacity (P = 0.09) was not significant. Conversely, arterial blood gas, 6-min walk test, cardiac fraction ejection, pain (P < 0.05), dyspnea (P < 0.01), cough (P < 0.05), fever (P < 0.01), weight loss (P < 0.01), performance status (P < 0.01), SF-36 physical (P < 0.01), SF-36 mental (P < 0.05), St. George's Respiratory Questionnaire symptom (P < 0.01), activity (P < 0.05), and impact on mood (P < 0.05) improved. At 12 months, the amelioration of pain, dyspnea, performance status, and physical-related quality of life parameters remained stable. Thereafter, all parameters progressively deteriorated, although pain and dyspnea still persisted above the baseline values even after 24 months in all survivors. Postoperative improvement of pain (P = 0.04), dyspnea (P = 0.04), 6-min walk test (P = 0.03), and SF-36 physical (P = 0.04) and mental (P = 0.03) components were positive prognosticators.

Conclusions: Extrapleural pneumonectomy has a significant and durable impact on function and symptoms as well as on physical and mental components of quality of life in patients with malignant pleural mesothelioma.

In plain English

This single-center series reviewed 29 consecutive patients having extrapleural pneumonectomy for malignant pleural mesothelioma, 1997 to 2007. One surgeon operated; chemotherapy then radiotherapy usually followed, but 21 patients (reported as 75%, apparently of 28 surviving surgery) received the planned chemotherapy cycles. One patient died within 30 days; 12 of 29 (41%) had major complications. Median survival was 19.5 months. Of 28 assessed at 3 months, pain improved in 22 (79%) and breathlessness in 17 (61%); lung-function drops were not statistically significant but fell after 12 months. Quality of life improved at 3 months. The authors wrote SF-36 domains reached or fell below baseline afterward; the median mental score went from 45 (29 patients) to 19 at 24 months (10 patients), though general health stayed above baseline (20 versus 25). Respiratory-questionnaire scores returned to preoperative levels after 24 months. Only non-epithelial tumor type predicted shorter survival in the final analysis; recorded asbestos exposure (22 patients) was not significantly linked to survival. The authors concluded it may have a durable clinical impact in selected patients, though without a control group they could not separate surgery's effects from adjuvant therapy's.

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: Single-surgeon case series of consecutive patients, with data collected prospectively and reviewed retrospectively; no control group
• Who was studied: 29 consecutive patients (22 men, 7 women; mean age 61, range 40 to 75) with malignant pleural mesothelioma, operated on from 1997 to 2007 by the same surgeon; the authors are from Tor Vergata University, Rome, Italy
• Exposure: Treatment studied: extrapleural pneumonectomy (15 right, 14 left), with planned adjuvant cisplatin plus gemcitabine chemotherapy (usually four to six cycles) followed by external-beam radiotherapy. Asbestos exposure was recorded as yes in 22 patients and no in 7; no fiber types are given
• Main results:
  • One 30-day postoperative death, due to pulmonary embolism. Major 30-day complications occurred in 41% (12 of 29)
  • Median follow-up was 16 months (range 0.2 to 158) and median survival was 19.5 months. 17 patients were alive after 1 year and 10 after 2 years
  • Adjuvant treatment: 21 patients, reported as 75%, received the planned chemotherapy cycles. The article does not state the denominator; 75% matches 21 of the 28 patients who survived the operation, not 21 of 29. Seven did not complete planned chemotherapy, and two progressed rapidly after only two cycles and were then suitable for supportive care only
  • At 3 months the decreases in forced expiratory volume in 1 s (P = 0.06) and forced vital capacity (P = 0.09) were not statistically significant. Respiratory parameters progressively decreased after 12 months
  • Among the 28 patients assessed at 3 months (Table 2), pain score improved in 22 (79%), with a significant median decrease (P less than 0.05) that stayed stable up to 12 months. Dyspnea improved in 17 (61%)
  • Number of patients assessed at 3 months was 28
  • The authors reported that pain and dyspnea scores remained better than baseline after 24 months in all 10 survivors
  • SF-36 quality of life at 3 months: 21 patients (75%) improved in physical domains and 20 (71%) in mental domains. The authors wrote that after 12 months only the physical domains stayed above baseline, and thereafter every domain declined, reaching or dropping below baseline
  • SF-36 mental component summary (Table 3): median 45 before surgery (29 patients) and 19 at 24 months (10 patients)
  • SF-36 general health (Table 3): median 20 before surgery (29 patients) and 25 at both 24 months (10 patients) and 36 months (5 patients), i.e. above baseline
  • St. George's Respiratory Questionnaire scores improved at 3 months, then all parameters worsened back to the preoperative status after 24 months
  • In univariate analysis, nonepithelial histology (P = 0.01) and mediastinal lymph node metastasis (P = 0.01) were associated with poorer prognosis. Absence of 3-month improvement in pain, dyspnea, 6-min walk test, performance status and SF-36 components was also associated with shorter survival
  • In Cox regression, nonepithelial histology was the only significant prognostic factor (hazard ratio 5.4, 95% confidence interval 3 to 15)
  • Asbestos exposure (22 yes vs 7 no) was not significantly associated with survival in Table 1 (median 18 vs 20 months, P = 0.4)
• The authors' conclusion: The authors concluded that extrapleural pneumonectomy plus adjuvant therapy may have a durable clinical impact in selected patients with malignant pleural mesothelioma. They said it can rapidly improve symptoms and quality of life without greatly impairing lung function
• Limitations the authors state:
  • No control group, so the authors could not determine whether improvement was due more to surgery or to adjuvant therapy
  • Persistent improvements could reflect a culling effect, because fewer patients were available for evaluation over time
  • Small sample size collected over a wide time span

Topics

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

Medical terms in this study, explained in our Lexicon: Extrapleural Pneumonectomy (EPP), Pleural Mesothelioma, Mesothelioma, Spirometry, Dyspnea, Performance Status, Quality of Life, Median Survival.

Related studies

• Impact of induction therapy on postoperative outcome after extrapleural pneumonectomy for malignant pleural mesothelioma: does induction-accelerated hemithoracic radiation increase the surgical risk? — P. Mordant, K. McRae, et al. (2016)
• Clinical and pathological features of three-year survivors of malignant pleural mesothelioma following extrapleural pneumonectomy — D.J. Sugarbaker, A.S. Wolf, et al. (2011)
• Extrapleural pneumonectomy for early stage malignant pleural mesothelioma: a harmful procedure — O. Rena, C. Casadio (2012)
• Clinical experience of volumetric modulated arc therapy for malignant pleural mesothelioma after extrapleural pneumonectomy — T. Kimura, Y. Doi, et al. (2015)
• Epithelial malignant pleural mesothelioma after extrapleural pneumonectomy: stratification of survival with CT-derived tumor volume — R.R. Gill, W.G. Richards, et al. (2012)
• Second surgery for recurrence of malignant pleural mesothelioma after extrapleural pneumonectomy — L. Politi, G. Borzellino (2010)

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