Complications and Predictive Factors for Air Leak \> 10 Days with Neoadjuvant Chemotherapy Followed by Pleurectomy/Decortication for Malignant Pleural Mesothelioma

Our plain-English summary of Complications and Predictive Factors for Air Leak > 10 Days with Neoadjuvant Chemotherapy Followed by Pleurectomy/Decortication for Malignant Pleural Mesothelioma, by A. Nakamura, N. Kondo, T. Nakamichi, et al (Annals of Surgical Oncology, 2021).

The study

• Authors: A. Nakamura, N. Kondo, T. Nakamichi, M. Hashimoto, T. Takuwa, S. Matsumoto, K. Kuribayashi, T. Kijima, S. Hasegawa
• Journal: Annals of Surgical Oncology
• Published: 2021;28(6):3057-3065
• Cited by: 13 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: A few studies have reported the incidence and clinical implications of complications after pleurectomy/decortication (P/D).

Objective: The aim of this study was to assess the details of complications and predictive factors of particularly durable air leak with P/D.

Methods: Data on 163 consecutive patients who underwent neoadjuvant chemotherapy (NAC) followed by P/D for malignant pleural mesothelioma between September 2012 and May 2020 at our institution were retrospectively analyzed. Postoperative complications and the significance of various preoperative risk factors for air leak > 10 days (AL10) to identify the group having a higher risk for particularly durable air leak were investigated. Risk factors for AL10 were sought using univariate and multivariate analyses.

Results: Of 163 patients, 30- and 90-day mortality was 0.6% and 2.5%, respectively. Eighty-four (51.4%) patients experienced grade III or worse postoperative complications according to the Clavien-Dindo classification. The median duration of air leak was 7 postoperative days. AL10 occurred in 53 (32.5%) patients. Fifty-eight patients (35.6%) underwent pleurodesis and five patients (3.1%) underwent reoperation to control the air leak. On univariate analysis, performance status (PS; p = 0.003), prognostic nutritional index (p = 0.01), and pleural effusion (p = 0.04) were statistically significant risk factors for AL10, while on multivariate analysis, PS (odds ratio 4.0, 95% confidence interval 1.3-12.7; p = 0.02) remained the only variable predicted for AL10.

Conclusions: Recent postoperative mortality rates in NAC followed by P/D are quite acceptable. Approximately one in every three patients experienced AL10, and PS may be a risk factor associated with AL10.

In plain English

This was a retrospective review of 163 patients with malignant pleural mesothelioma treated at one hospital in Japan between September 2012 and May 2020. All had three cycles of platinum plus pemetrexed chemotherapy before lung-sparing surgery to remove the pleura (pleurectomy/decortication). The article did not examine asbestos exposure. One patient (0.6%) died within 30 days of surgery and 4 (2.5%) within 90 days. Serious complications (grade III or worse) occurred in 84 patients (51.5%). The most frequent complication was air leaking from the lung, in 72 patients (44.2%). The air leak lasted more than 10 days in 53 patients (32.5%). To control air leak, 58 patients (35.6%) had pleurodesis and 5 (3.1%) had another operation. In the multivariate analysis, only a performance status score of 1 rather than 0 was significantly linked to air leak lasting more than 10 days (odds ratio 4.0, 95% confidence interval 1.3 to 12.7). The authors concluded that short-term outcomes were quite acceptable. They noted that the single-center, retrospective design may have introduced bias.

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 at a single institution
• Who was studied: 163 patients (138 male, 84.7%) with malignant pleural mesothelioma who had pleurectomy/decortication after neoadjuvant chemotherapy at Hyogo College of Medicine, Japan, September 2012 to May 2020. They came from 263 consecutive eligible patients: 210 had surgery, and 47 were excluded because they had extrapleural pneumonectomy or exploratory thoracotomy.
• Exposure: Three cycles of neoadjuvant chemotherapy with platinum (cisplatin or carboplatin) plus pemetrexed, followed by pleurectomy/decortication. Asbestos exposure was not studied.
• Main results:
  • 30-day mortality was 0.6% (one patient) and 90-day mortality was 2.5% (4 patients) among the 163 patients
  • Overall morbidity was 72.4% (118 patients); 84 patients (51.5%) had grade III or worse complications by the Clavien–Dindo classification
  • The most frequent postoperative complication was air leak, in 72 patients (44.2%), followed by atrial arrhythmia in 22 (13.5%)
  • Median air leak duration was 7 days (IQR 5–11.5). Air leak lasted more than 10 days in 53 patients (32.5%) and more than 14 days in 13 patients (8.0%).
  • 58 patients (35.6%) underwent pleurodesis (51 with a self-blood patch), and 5 patients (3.1%) needed reoperation to control air leak
  • Of the 53 patients with air leak lasting more than 10 days, 4 developed acute respiratory distress syndrome
  • In univariate analysis, factors significantly linked to air leak lasting more than 10 days were performance status score of 1 (p = 0.003), prognostic nutritional index below 48 (p = 0.01), and pleural effusion (p = 0.04)
  • In multivariate analysis, performance status score 1 vs 0 was the only significant risk factor (odds ratio 4.0, 95% CI 1.3–12.7; p = 0.02). Prognostic nutritional index (OR 2.0, 0.9–4.2; p = 0.07), pleural effusion (OR 1.7, 0.8–3.6; p = 0.1) and male sex (OR 2.3, 0.7–7.5; p = 0.2) were not statistically significant.
  • No significant difference was found for T stage, chronic obstructive pulmonary disease, smoking history, or pulmonary function
• The authors' conclusion: The authors concluded that short-term outcomes of neoadjuvant chemotherapy followed by pleurectomy/decortication are quite acceptable. About one-third of patients had air leak lasting more than 10 days, and most of these were treated conservatively with pleurodesis. They called a performance status score of 1 a significant risk factor; the abstract says performance status 'may be' a risk factor.
• Limitations the authors state:
  • The single-center, retrospective design may have introduced bias and problems with external validity
  • The more-than-10-day cut-off for durable air leak is arbitrary (general lung surgery uses more than 4–10 days), so the results should be interpreted carefully

Topics

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

Medical terms in this study, explained in our Lexicon: Neoadjuvant Chemotherapy, Pleurectomy/Decortication (P/D), Pleural Mesothelioma, Pleurodesis, Performance Status, Pleural Effusion, Multivariate Analysis, Odds Ratio.

Related studies

• Clinical Outcomes With Recurrence After Pleurectomy/Decortication for Malignant Pleural Mesothelioma — A. Nakamura, T. Takuwa, et al. (2020)
• Pleurectomy/decortication, hyperthermic pleural lavage with povidone-iodine followed by adjuvant chemotherapy in patients with malignant pleural mesothelioma — L. Lang-Lazdunski, A. Bille, et al. (2011)
• A phase II trial of pleurectomy/decortication followed by intrapleural and systemic chemotherapy for malignant pleural mesothelioma — V. Rusch, L. Saltz, et al. (1994)
• A feasibility study of induction pemetrexed plus cisplatin followed by pleurectomy/decortication aimed at macroscopic complete resection for malignant pleural mesothelioma — M. Shimokawa, S. Hasegawa, et al. (2013)
• Types of surgery post-neoadjuvant chemotherapy for pleural mesothelioma — K. Kuribayashi, H. Doi, et al. (2019)
• Pleurectomy/decortication, hyperthermic pleural lavage with povidone-iodine, prophylactic radiotherapy, and systemic chemotherapy in patients with malignant pleural mesothelioma: a 10-year experience — L. Lang-Lazdunski, A. Bille, et al. (2015)

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