Current surgical strategies for malignant pleural mesothelioma

Our plain-English summary of Current surgical strategies for malignant pleural mesothelioma, by T. Takuwa, S. Hasegawa (Surgery Today, 2016).

The study

• Authors: T. Takuwa, S. Hasegawa
• Journal: Surgery Today
• Published: 2016;46(8):887-94
• Type of article: Review
• Cited by: 23 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Malignant pleural mesothelioma (MPM) is associated with a poor prognosis. The main components of multimodality treatment include surgery, chemotherapy, and radiation therapy. Surgery remains controversial. Two procedures are currently offered: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). The recent scientific literature suggests that P/D is a well-tolerated procedure, with the potential of becoming a default procedure in multimodality regimens. However, the precise treatment schemes and surgical procedures are yet to be established. In our study, we review the advantages and disadvantages of EPP and P/D, summarize the post-EPP and post-P/D observations (including mortality, morbidity, and median survival time), and discuss the choice of surgical technique (EPP vs. P/D). Moreover, we highlight the aspects of the multimodality treatments that are offered to MPM patients, including chemotherapy, radiotherapy, intensity-modulated radiation therapy, and other types of therapy.

In plain English

This article was a narrative review by two authors at Hyogo College of Medicine in Japan. It looked at published studies on surgery for malignant pleural mesothelioma and collected no new patient data. It did not study asbestos exposure. It compared two operations. Extrapleural pneumonectomy (EPP) removes the pleura and the lung on that side. Pleurectomy/decortication (P/D) removes the pleura but spares the lung. Among the cited studies, a retrospective multicenter study by Flores et al. reported, after EPP, an operative death rate of 7% (27/385) and median survival of 12 months. After P/D it reported 4% (13/278) and 16 months. A systematic review by Cao et al. reported significantly lower operative death rates (2.9 vs. 6.8%) and complication rates (27.9 vs. 62%) with P/D. An international database found longer median survival with EPP than P/D in stage I disease (40 vs. 23 months). The authors noted that retrospective studies are subject to patient selection bias. They also noted that no randomized trials had compared the two operations. They concluded that the evidence was insufficient to say which surgery is better.

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: Narrative review article of published studies on surgery and multimodality treatment for malignant pleural mesothelioma
• Who was studied: No new patients were studied. The authors, at Hyogo College of Medicine, Japan, reviewed published studies of patients with malignant pleural mesothelioma treated with surgery.
• Exposure: Not an asbestos exposure study. The 'exposures' were treatments. Extrapleural pneumonectomy (EPP) removes the pleura and the lung on that side, and if needed the pericardium and diaphragm. Pleurectomy/decortication (P/D) removes the pleura and spares the lung. The review also covered chemotherapy, radiotherapy including intensity-modulated radiation therapy (IMRT), and other therapies.
• Main results:
  • A retrospective multicenter study by Flores et al. (cited, not this study's own data) reported an operative mortality of 7% (27/385) and a median survival of 12 months for EPP patients.
  • In the same Flores et al. study, P/D patients had an operative mortality of 4% (13/278) and a median overall survival of 16 months.
  • A systematic review by Cao et al. (P/D: N = 513; EPP: N = 632) reported median survival ranging from 13 to 29 months for P/D and from 12 to 22 months for EPP, with a trend favoring P/D.
  • In Cao et al., operative mortality was significantly lower in the P/D group than the EPP group (2.9 vs. 6.8%, P = 0.02).
  • In Cao et al., morbidity (complications) was also significantly lower in the P/D group (27.9 vs. 62%, P < 0.0001).
  • In the IASLC international database, among stage I patients having curative-intent surgery, median survival was significantly better with EPP than with P/D (40 vs. 23 months). No significant survival differences were found at higher stages.
  • The authors reported that no randomized controlled trials had compared EPP with P/D.
• The authors' conclusion: The authors concluded that the ideal treatment for MPM remains unknown. They found the evidence insufficient to decide whether EPP or P/D is better. They stated that surgery should be part of multimodality therapy for patients with early-stage disease and good performance status. They also stated it should be done in high-volume centers, with results discussed by a multidisciplinary tumor board.
• Limitations the authors state:
  • The authors noted that the retrospective studies comparing the operations are subject to patient selection bias. They also noted that no randomized trials have compared EPP with P/D.

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, Prognosis, Chemotherapy, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D), Median Survival, Intensity-Modulated Radiation Therapy (IMRT).

Related studies

• Current Treatment of Mesothelioma: Extrapleural Pneumonectomy Versus Pleurectomy/Decortication — A.S. Wolf, R.M. Flores (2016)
• Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma — S. Hasegawa (2014)
• Current surgical treatment of malignant pleural mesothelioma — K. Chihara (2018)
• Physical function and health-related quality of life in patients undergoing surgical treatment for malignant pleural mesothelioma — T. Tanaka, S. Morishita, et al. (2017)
• A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma — C. Cao, D. Tian, et al. (2014)
• Photodynamic therapy and the evolution of a lung-sparing surgical treatment for mesothelioma — J.S. Friedberg, R. Mick, et al. (2011)

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