Extended Pleurectomy-Decortication-Based Treatment for Advanced Stage Epithelial Mesothelioma Yielding a Median Survival of Nearly Three Years

Our plain-English summary of Extended Pleurectomy-Decortication-Based Treatment for Advanced Stage Epithelial Mesothelioma Yielding a Median Survival of Nearly Three Years, by J.S. Friedberg, C.B. Simone, M.J. Culligan, et al (The Annals of Thoracic Surgery, 2017).

The study

• Authors: J.S. Friedberg, C.B. Simone, M.J. Culligan, A.R. Barsky, A. Doucette, S. McNulty, S.M. Hahn, E. Alley, D.H. Sterman, E. Glatstein, K.A. Cengel
• Journal: The Annals of Thoracic Surgery
• Published: 2017;103(3):912-919
• Cited by: 108 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: The purpose of this study was to assess survival for patients with malignant pleural mesothelioma (MPM), epithelial subtype, utilizing extended pleurectomy-decortication combined with intraoperative photodynamic therapy (PDT) and adjuvant pemetrexed-based chemotherapy.

Methods: From 2005 to 2013, 90 patients underwent lung-sparing surgery and PDT for MPM. All patients had a preoperative diagnosis of epithelial subtype, of which 17 proved to be of mixed histology. The remaining 73 patients with pure epithelial subtype were analyzed. All patients received lung-sparing surgery and PDT; 92% also received chemotherapy. The median follow-up was 5.3 years for living patients.

Results: Macroscopic complete resection was achieved in all 73 patients. Thirty-day mortality was 3% and 90-day mortality was 4%. For all 73 patients (89% American Joint Commission on Cancer stage III/IV, 69% N2 disease, median tumor volume 550 mL), the median overall and disease-free survivals were 3 years and 1.2 years, respectively. For the 19 patients without lymph node metastases (74% stage III/IV, median tumor volume 325 mL), the median overall and disease-free survivals were 7.3 years and 2.3 years, respectively.

Conclusions: This is a mature dataset for MPM that demonstrates the ability to safely execute a complex treatment plan that included a surgical technique that consistently permitted achieving a macroscopic complete resection while preserving the lung. The role for lung-sparing surgery is unclear but this series demonstrates that it is an option, even for advanced cases. The overall survival of 7.3 years for the node negative subset of patients, still of advanced stage, is encouraging. Of particular interest is the overall survival being approximately triple the disease-free survival, perhaps PDT related. The impact of PDT is unclear, but it is hoped that it will be established by an ongoing randomized trial.

Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

In plain English

This was a retrospective analysis of patients treated in two prospective clinical trials. From 2005 to 2013, 90 patients diagnosed before surgery with epithelial malignant pleural mesothelioma had lung-sparing surgery (extended pleurectomy-decortication) with photodynamic therapy during the operation. Most also had pemetrexed-based chemotherapy. The 73 whose final pathology confirmed pure epithelial disease were analyzed, and most had stage III or IV cancer. The article does not discuss asbestos exposure. The authors reported macroscopic complete resection in all 73. Two patients died within 30 days and three within 90 days. For all 73, median overall survival was 36 months and disease-free survival was 14 months. The 19 patients without lymph node spread had a median overall survival of 87 months, compared with 23 months for those with node involvement. Men did worse than women (26 versus 57 months). Pneumonia occurred in 28%. The authors concluded the approach consistently preserved the lung and gave promising results, especially without node spread. They noted that the study was retrospective, that chemotherapy varied, and that 19 patients were too few for definitive conclusions.

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 analysis of all patients treated in two prospective clinical trials (single-surgeon treatment series)
• Who was studied: 73 patients with pure epithelial malignant pleural mesothelioma, out of 90 who had a preoperative epithelial diagnosis and underwent lung-sparing surgery and photodynamic therapy from 2005 to 2013. The trials were approved by the University of Pennsylvania Institutional Review Board. Median age was 65; there were 55 men and 18 women.
• Exposure: The article does not report asbestos exposure. What was studied was a treatment: extended pleurectomy-decortication, intraoperative photodynamic therapy (photosensitizer porfimer sodium in 52 patients, HPPH in 21), and chemotherapy, generally pemetrexed-based doublet chemotherapy after surgery.
• Main results:
  • Macroscopic complete resection was achieved in all 73 pure epithelial patients. The surgical methods note that, in rare cases where the entire visceral pleura could not be resected, detectable disease was cauterized.
  • Most of the 73 patients had advanced disease: stage III in 37 of 73 (50%) and stage IV in 28 of 73 (39%)
  • 30-day mortality was 2 of 73 (3%); 90-day mortality was 3 of 73 (4%)
  • At a median follow-up of 5.3 years for living patients, median overall survival was 36 months and disease-free survival was 14 months for all 73 patients
  • Median overall and disease-free survival were 23 and 10 months for node-positive (N1/2) patients, and 87 and 27 months for the 19 node-negative (N0) patients
  • Overall survival was worse in men than in women, 26 versus 57 months (p = 0.0142)
  • Age, stage III versus IV, and photosensitizer type were not statistically significantly associated with survival
  • Pneumonia occurred in 28% of patients, a rate the authors called high and potentially related to photodynamic therapy. Other complications included atrial fibrillation in 21 of 73 (28%) and respiratory failure requiring tracheostomy in 14 of 73 (19%).
• The authors' conclusion: The authors concluded that, despite significant limitations, the study validates a surgical approach that consistently preserved the lung and yielded some promising results, particularly for advanced-stage patients without nodal metastases. They also stated that whether photodynamic therapy played a role is unknown.
• Limitations the authors state:
  • Retrospective, with significant variability in how chemotherapy was given
  • Two different photosensitizers were used, and quality of life was not measured
  • No adjustment for confounders in the analysis
  • The node-negative group (19 patients) was too small for definitive 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: Pleurectomy/Decortication (P/D), Mesothelioma, Median Survival, Pleural Mesothelioma, Pemetrexed (Alimta), Chemotherapy, Histology, Disease-Free Survival.

Related studies

• Lymphangitic carcinomatosis: A common radiographic manifestation of local failure following extended pleurectomy/decortication in patients with malignant pleural mesothelioma — I. Berger, K.A. Cengel, et al. (2019)
• Long-term survival after lung-sparing total pleurectomy for locally advanced (International Mesothelioma Interest Group Stage T3-T4) non-sarcomatoid malignant pleural mesothelioma — A. Nakas, E. von Meyenfeldt, et al. (2012)
• Radical pleurectomy and intraoperative photodynamic therapy for malignant pleural mesothelioma — J.S. Friedberg, M.J. Culligan, et al. (2012)
• Extended Pleurectomy and Decortication for Malignant Pleural Mesothelioma Is an Effective and Safe Cytoreductive Surgery in the Elderly — T. Williams, H. Duraid, et al. (2015)
• 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)
• Prolonged survival and novel prognostic factors in women with pleural mesothelioma treated with extended pleurectomy decortication — M. Lapidot, E. Mazzola, et al. (2024)

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