Current Treatment of Mesothelioma: Extrapleural Pneumonectomy Versus Pleurectomy/Decortication

Our plain-English summary of Current Treatment of Mesothelioma: Extrapleural Pneumonectomy Versus Pleurectomy/Decortication, by A.S. Wolf, R.M. Flores (Thoracic Surgery Clinics, 2016).

The study

• Authors: A.S. Wolf, R.M. Flores
• Journal: Thoracic Surgery Clinics
• Published: 2016;26(3):359-75
• Type of article: Review
• Cited by: 30 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

The role of surgical resection in malignant pleural mesothelioma (MPM) is based on the principle of macroscopic resection of a solid tumor with adjuvant therapy to treat micrometastatic disease. Extrapleural pneumonectomy (EPP) and pleurectomy decortication (P/D) have been developed in this context. Cancer-directed surgery for MPM is associated with a 5-year survival rate of 15%. Evidence indicates that P/D is better tolerated by patients and suggests survival is no worse when compared with EPP. Although EPP is still performed in highly selected cases, the authors advocate radical P/D whenever possible for patients with MPM.

Copyright © 2016 Elsevier Inc. All rights reserved.

In plain English

This article was a narrative review of the two main operations for malignant pleural mesothelioma (MPM). Extrapleural pneumonectomy (EPP) removes the lung, both layers of pleura, the diaphragm and the pericardium. Pleurectomy/decortication (P/D) removes the pleura but keeps the lung. The authors described how patients are evaluated, how each operation is done and how patients are cared for afterward, and they summarized published results. They reported no new patient data and did not study asbestos exposure. The review stated that P/D is associated with fewer complications and deaths around the time of surgery. It cited a meta-analysis of 24 datasets (1391 EPP and 1512 P/D patients) that found higher 30-day mortality after EPP (4.5% vs 1.7%). Of 17 studies in that analysis reporting median survival, 53% reported longer survival with EPP and 47% with P/D. The authors noted that a randomized trial (MARS) did not succeed in randomizing patients. They concluded that survival after P/D appears no worse, and they advocated radical P/D whenever possible.

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 of published studies on surgery for malignant pleural mesothelioma, including description of surgical technique and a summary of a previously published meta-analysis
• Who was studied: Published studies of patients with malignant pleural mesothelioma treated with EPP or P/D. The central evidence was a meta-analysis of English-language observational studies from 1990 to 2014, covering 24 datasets with 1391 EPP patients and 1512 P/D patients.
• Exposure: Two surgical procedures, usually given with chemotherapy, radiation or other added treatments. Extrapleural pneumonectomy removes the lung, pleurae, diaphragm and pericardium. Pleurectomy/decortication removes the pleurae and always preserves the lung. Asbestos exposure was not the subject of the review.
• Main results:
  • The review stated that P/D is associated with better short-term outcomes than EPP, meaning fewer complications and deaths around the time of surgery.
  • In the cited meta-analysis, 30-day mortality was significantly higher with EPP (4.5%) than with P/D (1.7%), with little variation between studies.
  • Of the 17 studies in the meta-analysis that reported median survival, 53% reported higher median survival with EPP and 47% with P/D.
  • Of the 7 studies in the meta-analysis reporting survival of at least 2 years, survival was similar for EPP and P/D, but there was significant variation among studies.
  • A cited study of the Society of Thoracic Surgeons Database found higher rates of acute respiratory distress syndrome, reintubation, unexpected reoperation, sepsis and death after EPP than after P/D.
  • A cited retrospective study of 663 patients concluded that cumulative survival was higher with P/D for early-stage disease and higher with EPP for later-stage disease.
  • The authors wrote that the evidence suggests survival after P/D is no worse than after EPP.
• The authors' conclusion: The authors concluded that P/D is better tolerated and that survival appears no worse. Although EPP is still performed in certain cases, they advocated radical P/D whenever possible for patients with MPM.
• Limitations the authors state:
  • The authors stated that single-center studies have been biased in favor of one procedure or the other.
  • The MARS randomized trial, designed to compare EPP with no surgery, did not succeed in randomizing patients.
  • Later exploratory analyses of long-term outcomes from that trial lacked enough statistical power to draw meaningful conclusions.

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: Mesothelioma, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D), Surgical Resection, Pleural Mesothelioma, Adjuvant Therapy.

Related studies

• Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma — E. Taioli, A.S. Wolf, et al. (2015)
• Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma — S. Hasegawa (2014)
• Extrapleural Pneumonectomy Versus Pleurectomy/Decortication for Malignant Pleural Mesothelioma — N. Zhou, D.C. Rice, et al. (2022)
• Short-term outcomes of pleurectomy decortication and extrapleural pneumonectomy in mesothelioma — M. van Gerwen, A. Wolf, et al. (2018)
• Extrapleural Pneumonectomy and Pleurectomy Decortication: Can We Really Compare Their Survival? — P. Bertoglio, S. Korasidis (2015)
• Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma — L. Lang-Lazdunski, A. Bille, et al. (2012)

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