Extended Pleurectomy and Decortication for Malignant Pleural Mesothelioma Is an Effective and Safe Cytoreductive Surgery in the Elderly

Our plain-English summary of Extended Pleurectomy and Decortication for Malignant Pleural Mesothelioma Is an Effective and Safe Cytoreductive Surgery in the Elderly, by T. Williams, H. Duraid, S. Watson, et al (The Annals of Thoracic Surgery, 2015).

The study

• Authors: T. Williams, H. Duraid, S. Watson, A. Durkin, K. Todd, H.L. Kindler, W.T. Vigneswaran
• Journal: The Annals of Thoracic Surgery
• Published: 2015;100(5):1868-74
• Cited by: 19 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: A survival advantage has been observed among patients with malignant pleural mesothelioma undergoing maximal cytoreductive surgery and adjuvant therapy. Elderly patients are considered higher risk for these radical operations and are commonly not offered surgical treatment. We reviewed our experience with extended pleurectomy and decortication among patients 70 years or older and compared them with a cohort of younger patients undergoing extended pleurectomy and decortication for malignant pleural mesothelioma.

Methods: We performed a retrospective review of 117 consecutive patients undergoing extended pleurectomy and decortication at a university hospital from January 2008 to December 2013. Patients 70 years and older were compared with younger patients for postoperative outcome and survival. Survival was estimated using the Kaplan-Meier method.

Results: Fifty-four patients were 70 years or older; 63 were younger than 70 years. Older patients had more hypertension (71.2% versus 45.2%; p = 0.004) and coronary artery disease (22.6% versus 6.5%; p = 0.006). Major complications occurred in 3 patients (5.5%) in the older group and in 7 patients (11.1%) of the younger group (not significant). There were 2 deaths in each group after surgery (3.7% older versus 3.2% younger; not significant). Median survival was 15.6 months in the older patients and 14.0 months in the younger patients (not significant). Kaplan-Meier survival curves based on age groups were not significantly different with 1- and 2-year survivals of 64% versus 55% and 29% versus 32%, respectively.

Conclusions: Our study demonstrates that whereas age may be associated with more comorbid conditions in patients with malignant pleural mesothelioma undergoing extended pleurectomy and decortication, this does not necessarily translate into increased operative morbidity or mortality or shorter long-term survival.

Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

In plain English

This study reviewed the records of 117 consecutive patients with malignant pleural mesothelioma who had extended pleurectomy and decortication surgery. One surgeon operated at a single institution between January 2008 and December 2013. The study did not examine asbestos exposure. It compared 54 patients aged 70 or older with 63 younger patients. The older group had significantly more high blood pressure and coronary artery disease. Two patients in each group died within 30 days of surgery or in hospital (3.7% older versus 3.2% younger). Major complications occurred in 3 older and 7 younger patients, minor ones in 17 older and 18 younger. The differences in deaths and complications were not statistically significant. Median survival after surgery was 15.6 months in older and 14.0 months in younger patients, also not significantly different. Age did not predict survival in the statistical models. Pure epithelioid tumor type, performance status (a measure of daily functioning) and chemotherapy after surgery did. The authors concluded that this surgery should be offered to elderly patients who are otherwise fit. They noted survival was counted from surgery, not diagnosis.

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 patients treated at a single institution by one surgeon, comparing patients aged 70 and older with younger patients
• Who was studied: 117 consecutive patients with malignant pleural mesothelioma who underwent extended pleurectomy and decortication at a single university hospital (University of Chicago Medicine) from January 2008 to December 2013: 54 aged 70 or older (range 70 to 88) and 63 younger than 70 (range 43 to 69.9); 94 were men
• Exposure: The study did not examine asbestos exposure. The factor compared was age (70 and older versus younger than 70) among patients undergoing extended pleurectomy and decortication
• Main results:
  • The group aged 70 and older had more hypertension and coronary artery disease than the younger group. Table 1 gives hypertension as 70.1% (38) of older versus 47.6% (30) of younger patients (p = 0.004), and coronary artery disease as 24.1% (13) versus 6.3% (4) (p = 0.015)
  • Operative mortality (death within 30 days or while in hospital) was 2 patients in each group: 3.7% of older versus 3.2% of younger patients, not statistically significant
  • Major complications occurred in 3 older patients (5.5%) versus 7 younger patients (not significant). Minor complications occurred in 17 (30.1%) older and 18 (29%) younger patients (not significant)
  • 1-, 2- and 3-year survival was 64%, 29% and 13% in the older patients and 55%, 32% and 20% in the younger patients. The Kaplan-Meier curves showed no difference by age
  • Median survival was 15.6 months in older and 14.0 months in younger patients (not significant). Overall median survival was 14.4 months, with median follow-up of 14.3 months
  • In Cox regression, the only significant predictors of survival were pure epithelioid histologic subtype (hazard ratio 0.41, p less than 0.001), performance status (hazard ratio 1.8, p = 0.04) and receipt of adjuvant therapy (hazard ratio 0.43, p = 0.004). Age and T stage were not significant predictors
  • Among younger patients, median survival was 23.9 months with performance status 0 versus 11.3 months with performance status 1 (p = 0.002). Among older patients it was 20.1 versus 15 months (not significant)
• The authors' conclusion: The authors concluded that older patients had more comorbidities but that the operation did not increase short- or long-term morbidity or mortality in this group. They believe it should be offered to elderly patients with malignant pleural mesothelioma who are otherwise fit for surgery
• Limitations the authors state:
  • Survival was calculated from the day of surgery rather than the day of diagnosis
  • About 15% of patients in each group had no nodal examination because of inconsistent pathologic assessment earlier in the series
  • Some subgroups were small, including the T1 group and patients with sarcomatoid or less common tumor subtypes
  • There was selection bias in who received adjuvant chemotherapy, so its true effect is unclear

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, Cytoreductive Surgery, Adjuvant Therapy, Median Survival.

Related studies

• Extended pleurectomy decortication for thymoma with pleural dissemination — N. Imanishi, Y. Nabe, et al. (2019)
• Laparoscopy is Safe and Accurate to Evaluate Peritoneal Surface Metastasis Prior to Cytoreductive Surgery — R.A. Marmor, K.J. Kelly, et al. (2016)
• Quality of life after radical pleurectomy decortication for malignant pleural mesothelioma — N.M. Mollberg, Y. Vigneswaran, et al. (2012)
• Pleurectomy/decortication for palliation in malignant pleural mesothelioma: results of surgery — O. Soysal, N. Karaoğlanoğlu, et al. (1997)
• Effects of extended pleurectomy and decortication on quality of life and pulmonary function in patients with malignant pleural mesothelioma — D. Burkholder, D. Hadi, et al. (2015)
• Influence of Pleurectomy and Decortication in Health-Related Quality of Life Among Patients with Malignant Pleural Mesothelioma — W.T. Vigneswaran, D.Y. Kircheva, et al. (2018)

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