Does surgery improve survival of patients with malignant pleural mesothelioma?: a multicenter retrospective analysis of 1365 consecutive patients

Our plain-English summary of Does surgery improve survival of patients with malignant pleural mesothelioma?: a multicenter retrospective analysis of 1365 consecutive patients, by P. Bovolato, C. Casadio, A. Billè, et al (Journal of Thoracic Oncology, 2014).

The study

• Authors: P. Bovolato, C. Casadio, A. Billè, F. Ardissone, L. Santambrogio, G.B. Ratto, G. Garofalo, A.V. Bedini, M. Garassino, L. Porcu, V. Torri, U. Pastorino
• Journal: Journal of Thoracic Oncology
• Published: 2014;9(3):390-6
• Cited by: 114 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Surgery with pleurectomy/decortication (P/D) or extrapleural pneumonectomy (EPP) can be an option for selected patients with resectable malignant pleural mesothelioma (MPM). The aim of this study was to investigate the impact of surgical treatment on the outcome of patients with MPM.

Methods: We retrospectively reviewed data from 1365 consecutive patients with histologically proven MPM, treated from 1982 to 2012 in six Institutions. Patients received chemotherapy alone (n = 172), best supportive care (n = 690), or surgical treatment (n = 503), by either P/D (n = 202) or EPP (n = 301) with or without chemotherapy.

Results: After a median follow-up of 6.7 years (range, 1.1-14.8), 230 patients (16.8%) were alive; median survival for patients who received palliative treatment or chemotherapy alone, P/D, and EPP were 11.7 (95% CI, 10.5-12.5), 20.5 (95% CI, 18.2-23.1), and 18.8 (95% CI, 17.2-20.9) months, respectively. The 30-day mortality was 2.6% after P/D and 4.1% after EPP (p = 0.401). According to multivariate analysis (n = 1227), age less than 70, epithelial histology, and chemotherapy were independent favorable prognostic factors. In the subset of 313 patients (25.5%) with all favorable prognostic factors, median survival was 18.6 months after medical therapy alone, 24.6 months after P/D, and 20.9 months after EPP (p = 0.596).

Conclusions: Our data suggest that patients with good prognostic factors had a similar survival whether they received medical therapy only, P/D, or EPP. The modest benefit observed after surgery during medical treatment requires further investigation, and a large multicenter, randomized trial, testing P/D after induction chemotherapy versus chemotherapy alone in MPM patients with good prognostic factors, is needed.

In plain English

The authors reviewed records of 1,365 consecutive patients with biopsy-confirmed malignant pleural mesothelioma, biopsied between September 1982 and September 2012 at six Italian institutions. Patients received chemotherapy alone (172), best supportive care (690), or surgery with or without chemotherapy: pleurectomy/decortication (P/D, 202) or extrapleural pneumonectomy (EPP, 301). Asbestos exposure was recorded but not reported in relation to survival. Median survival was 11.7 months without surgery (95% confidence interval 10.5 to 12.5, called a range in the results section), 20.5 months after P/D (18.2 to 23.1) and 18.8 months after EPP (17.2 to 20.9). Complications followed surgery in 10.4% of P/D patients and 21.6% of EPP patients. In an adjusted analysis of 1,227 patients, age, tumor cell type and surgery were independent factors linked to survival. Among 313 patients under 70 with epithelioid tumors who received chemotherapy, survival differences between treatments were not statistically significant. The authors concluded that survival might be slightly better after surgery, similar for P/D and EPP, and called for a randomized trial. They noted serious limitations, including the retrospective design and differing practices between centers.

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 multicenter study of consecutive patients, using Cox regression and Kaplan–Meier survival analysis
• Who was studied: 1,365 consecutive patients with histologically proven malignant pleural mesothelioma who had a thoracoscopic (n = 1282) or open (n = 83) pleural biopsy between September 1982 and September 2012 at six institutions in Italy (Brescia, Novara, Orbassano (Torino), Milan (two), Genova); 68.1% were male
• Exposure: Treatment, not asbestos, was the factor studied. Groups were medical treatment alone (chemotherapy, n = 172, or best supportive care, n = 690) or surgery with or without chemotherapy (P/D, n = 202, of whom 6 had only pleurectomy; EPP, n = 301). Chemotherapy was cisplatin and/or gemcitabine before 2004 and cisplatin plus pemetrexed after that. Asbestos exposure was recorded as a patient characteristic, but no survival result for it is reported.
• Main results:
  • Patients who received palliative treatment or chemotherapy alone had a median survival of 11.7 months, with 2- and 5-year survival rates of 19% and 4%. The interval 10.5–12.5 months is given as a 95% CI in the article's abstract and as a range in its results section.
  • Patients who had P/D had a median survival of 20.5 months (95% CI, 18.2–23.1), with 2- and 5-year survival rates of 40% and 10%.
  • Patients who had EPP had a median survival of 18.8 months (95% CI, 17.2–20.9), with 2- and 5-year survival rates of 37% and 12%.
  • Crude mortality at 30 and 90 days was 2.6% and 6% after P/D, and 4.1% and 6.9% after EPP. The differences were not statistically significant (p = 0.401 at 30 days; p = 0.713 at 90 days).
  • Postoperative complications occurred in 21 P/D patients (10.4%) and 65 EPP patients (21.6%). The difference was statistically significant (p less than 0.001).
  • In the multivariate analysis of 1,227 patients, age, histology and surgical treatment were independent prognostic factors. Hazard ratios were 0.77 (95% CI, 0.64–0.93) for EPP and 0.69 (95% CI, 0.55–0.86) for P/D compared with nonsurgical patients. Chemotherapy had a hazard ratio of 0.91 (95% CI, 0.77–1.09; p = 0.309).
  • Among 313 patients younger than 70 with epithelioid mesothelioma who received chemotherapy, median survival was 24.6 months (95% CI, 20.5–29.0) after P/D, 20.9 months (95% CI, 17.6–23.4) after EPP and 18.6 months (95% CI, 16.2–24.9) without surgery. The difference was not statistically significant (p = 0.596).
  • Survival improved in all three groups after pemetrexed was introduced (nonsurgical 10.9 to 15.3 months; P/D 19.5 to 23 months; EPP 17.2 to 23.3 months). The effect of treatment type on survival did not differ significantly between the two periods (p = 0.333).
• The authors' conclusion: The authors concluded that patients with favorable prognostic factors had similar survival whether they received chemotherapy alone, P/D or EPP. They said that overall, survival might be slightly better for surgical patients, with similar outcomes for P/D and EPP. They called for a large multicenter trial comparing P/D after induction chemotherapy with chemotherapy alone in patients with favorable prognostic factors.
• Limitations the authors state:
  • The authors described serious limitations: the retrospective design, different treatment approaches among the centers, and biases from different selection criteria and the long study period.
  • Comorbidity data were of limited quality, particularly for the nonsurgical group.
  • The stage-by-stage analyses had reduced statistical power because of large amounts of missing data and the small number of pathological stage IV patients (37).

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, Pleurectomy/Decortication (P/D), Extrapleural Pneumonectomy (EPP), Chemotherapy, Median Survival, Palliative Care, Multivariate Analysis, Histology.

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