Comorbidity, postoperative morbidity and survival in patients undergoing radical surgery for malignant pleural mesothelioma

Our plain-English summary of Comorbidity, postoperative morbidity and survival in patients undergoing radical surgery for malignant pleural mesothelioma, by M. Infante, E. Morenghi, E. Bottoni, et al (European Journal of Cardio-thoracic Surgery, 2016).

The study

• Authors: M. Infante, E. Morenghi, E. Bottoni, P. Zucali, D. Rahal, A. Morlacchi, A.M. Ascolese, F. De Rose, P. Navarria, A. Crepaldi, A. Testori, E. Voulaz, V. Errico, M. Perrino, M. Scorsetti, A. Chiti, A. Santoro, M. Alloisio
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2016;50(6):1077-1082
• Cited by: 27 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objectives: We examined a series of malignant pleural mesothelioma (MPM) patients who underwent radical surgery to explore relationships among comorbidity, postoperative morbidity and survival.

Methods: A retrospective analysis was carried out of all MPM patients operated on in a single centre from 2000 to 2015. The Charlson Comorbidity Index (CCI) was used to classify patients according to their underlying condition. Postoperative complications were scored according to WHO-derived criteria. Survival comparisons were performed by Cox analysis.

Results: Ninety-one patients underwent extrapleural pneumonectomy (EPP), 47 underwent pleurectomy decortication (PD) and 25 underwent palliative pleurectomy. The mean CCI of PD patients was significantly higher compared with that of EPP patients (P= 0.044). The frequency of grade 3+ complications was similar between EPP and PD (27 vs 26%). However, EPP patients had a 6-fold higher frequency of pleural sepsis (24 vs 4%, P= 0.002) occurring up to 695 days postoperatively. Median overall survival was 19 months (95% CI 13-25) after EPP, 30 months (95% CI 20-35) after PD and 13 months (95% CI 5-32) after palliative pleurectomy. At multivariate analysis, CCI (P< 0.001), histology (P= 0.014) and pleural sepsis (P= 0.001), but not complete resection, were significantly associated with survival. There was a trend in favour of PD over palliative resection after adjusting for histology and CCI.

Conclusions: The CCI is an independent predictor of survival in MPM patients undergoing radical surgery. Owing to its significant frequency and adverse impact, pleural sepsis may contribute to a reduced life expectancy after EPP. Surgical treatment of MPM remains debatable.

© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

In plain English

This retrospective review covered malignant pleural mesothelioma patients treated in Milan, Italy, from 2000 to 2014. Of 582 referred, 163 were selected for radical surgery: 91 had extrapleural pneumonectomy (EPP, removing a lung), 47 pleurectomy decortication (PD, sparing it), 25 palliative pleurectomy only. Comorbidity was scored with the age-adjusted Charlson Comorbidity Index (CCI). Severe complications were similar after EPP (27%, 95% CI 19 to 38) and PD (26%, 95% CI 14 to 40). Pleural sepsis (chest-cavity infection) followed 22 of 91 EPPs (24%, 95% CI 16 to 34), some up to 695 days later, and 2 of 47 PDs (4%, 95% CI 1 to 15). Median survival was 19 months (95% CI 13 to 25) after EPP, 30 (95% CI 20 to 35) after PD and 13 (95% CI 5 to 32) after palliative pleurectomy (P = 0.139, not statistically significant). Adjusted analysis significantly associated CCI, tumour cell type and pleural sepsis with survival, but not complete resection. The authors concluded CCI independently predicts survival and pleural sepsis may shorten life after EPP. They noted the study was not randomised.

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: Retrospective review of consecutive patients treated at a single centre
• Who was studied: Patients with malignant pleural mesothelioma referred to the Humanitas Research Hospital, Milan, Italy. Of 582 referred from January 2000 to September 2014, 163 (28%) were selected for surgery with radical intent.
• Exposure: Type of surgery: extrapleural pneumonectomy in 91 patients, pleurectomy decortication in 47 (14 standard and 33 extended), and palliative pleurectomy in 25. Comorbidity burden was measured by the age-adjusted Charlson Comorbidity Index. No asbestos fiber types or exposure doses were studied.
• Main results:
  • The mean age-adjusted CCI was higher in PD patients (2.32 plus or minus 1.02) than in EPP patients (1.90 plus or minus 1.34), P = 0.044.
  • Grade 3 or higher complications occurred in 25 EPP patients (27%, 95% CI 19 to 38), 12 PD patients (26%, 95% CI 14 to 40) and 2 palliative pleurectomy patients (8%, 95% CI 1 to 26).
  • Major complications and 30- and 90-day mortality did not differ significantly between EPP and PD.
  • Overall pleural sepsis (early plus late) occurred in 22 of 91 EPP patients (24%, 95% CI 16 to 34), 2 of 47 PD patients (4%, 95% CI 1 to 15) and 1 of 25 palliative pleurectomy patients (4%, 95% CI 0 to 20), P = 0.002.
  • In the EPP group, 9 patients (10%) developed pleural sepsis within 30 days. In 13 more EPP patients (14%), it occurred 32 to 695 days after surgery.
  • Among EPP patients, pleural sepsis was significantly more frequent after right-sided EPP (18 cases) than after left-sided EPP (4 cases), P = 0.001.
  • Median overall survival was 19 months (95% CI 13 to 25) for EPP patients, 30 months (95% CI 20 to 35) for PD patients and 13 months (95% CI 5 to 32) for palliative pleurectomy patients.
  • In Table 2, the P-value reported for overall survival across the three surgical groups was 0.139, which is not statistically significant.
  • In multivariate analysis, only the CCI, histology and pleural sepsis remained significantly associated with overall survival. Complete resection was not statistically significant in the model.
  • Multivariate hazard ratio for overall survival per unit of CCI: 1.38 (95% CI 1.19 to 1.61), P less than 0.001.
  • Multivariate hazard ratio for overall survival for pleural sepsis: 2.33 (95% CI 1.44 to 3.78), P = 0.001.
  • Multivariate hazard ratio for overall survival for epithelioid histology: 0.45 (95% CI 0.24 to 0.85), P = 0.014.
  • After adjusting for histology and comorbidity, there was a trend favouring PD over palliative pleurectomy (P = 0.050). EPP showed no significant difference from palliative pleurectomy (P = 0.186).
  • The factor listed as 'Asbestos' in the survival table was not significantly associated with overall survival in univariate analysis: hazard ratio 1.36 (95% CI 0.94 to 1.97), P = 0.098.
• The authors' conclusion: The authors concluded that the CCI is a strong independent predictor of postoperative complications and survival in malignant pleural mesothelioma, and that pleural sepsis may independently contribute to reduced life expectancy after EPP. They said whether PD-based treatment gives a survival advantage over chemotherapy alone still needs to be tested in a randomized setting.
• Limitations the authors state:
  • The study was not a randomized trial.
  • Subgroup analyses involved small numbers, and important prognostic factors may have been unevenly distributed, for example more biphasic histology in the palliative pleurectomy group.
  • Potential prognostic factors such as haemoglobin levels, white blood cell counts and tumour volume were not analysed.
  • Patients were enrolled over a long period, so treatment approaches changed over time.
  • Lung function was not systematically assessed during follow-up.

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: Pleural Mesothelioma, Extrapleural Pneumonectomy (EPP), Palliative Care, Median Overall Survival, Multivariate Analysis, Histology, Life Expectancy.

Related studies

• Use of postoperative creatinine to predict sustained kidney injury in patients undergoing mesothelioma surgery — K.A. Mizuguchi, A. Mitani, et al. (2012)
• Predictors of long-term survival following radical surgery for malignant pleural mesothelioma — A. Nakas, D. Waller (2014)
• Postoperative morbidity and mortality after pneumonectomy: a 30-year experience of 2064 consecutive patients — C. Pricopi, P. Mordant, et al. (2015)
• Postoperative Complications Independently Predict Cancer-Related Survival in Peritoneal Malignancies — M.H.A. Choudry, Y. Shuai, et al. (2018)
• Outcomes of Cytoreductive Surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients older than 70 years; survival benefit at considerable morbidity and mortality — K.I. Votanopoulos, N.A. Newman, et al. (2013)
• Postoperative outcomes of laparoscopic vs open cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for treatment of peritoneal surface malignancies — G. Passot, N. Bakrin, et al. (2014)

Browse more research in European Journal of Cardio-thoracic Surgery, or return to medical research.