Extrapleural pneumonectomies for pleural mesothelioma

Our plain-English summary of Extrapleural pneumonectomies for pleural mesothelioma, by E. Faccioli, A. Bellini, M. Mammana, et al (Expert Review of Respiratory Medicine, 2020).

The study

• Authors: E. Faccioli, A. Bellini, M. Mammana, N. Monaci, M. Schiavon, F. Rea
• Journal: Expert Review of Respiratory Medicine
• Published: 2020;14(1):67-79
• Type of article: Systematic review
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: Malignant pleural mesothelioma (MPM) is a fatal malignancy for which there is no definitive cure. The most effective multimodality treatment in prolonging survival is still matter of debate. Surgery remains one of the cornerstones in the multimodality therapy for MPM. Extra-pleural pneumonectomy and pleurectomy/decortication are the two main curative-intent procedures; however, the superiority of one technique over the other is still debated. This review aims to assess short- and long-term results of extrapleural pneumonectomy for MPM.Areas covered: This article focuses on the role of extrapleural pneumonectomy in MPM. A systematic review was performed by using electronic databases to identify studies that included patients treated by this procedure for MPM. Endpoints included overall survival, disease-free survival, recurrence rate, perioperative mortality, and morbidity.Expert commentary: This paper offers an overview of the results that are currently obtained in patients undergoing extrapleural pneumonectomy for MPM. The benefit of surgical treatments in MPM is still debated and its primary goal should be the achievement of a macroscopic complete resection. Several alternative multimodality protocols exist, with specific advantages and drawbacks; therefore, individualization of care for each patient is fundamental. The complexity of the surgical treatment mandates that patients be referred to specialized centers.

In plain English

This was a systematic review. The authors searched medical databases for studies of extrapleural pneumonectomy (EPP) in malignant pleural mesothelioma. EPP removes the lung and pleura; the article describes removal of the pericardium and diaphragm both as part of the operation and as done if required. They included 32 studies published between 1999 and 2019, covering 4369 patients. Twenty-six of the studies were retrospective. Median overall survival ranged from 10.2 to 46.9 months. For epithelial mesothelioma the text gives 20.9 to 51 months, but its own table lists 17.1 months for one epithelial subgroup. Death within 30 days ranged from 0% to 11.2%, and within 90 days from 3.4% to 17%. Overall complication rates ranged from 21.6% to 73%, and heart rhythm disturbances were the most frequent complication. Recurrence ranged from 31% to 81%. Most studies reported more distant than local recurrence. The authors concluded that it cannot be established with certainty whether EPP or pleurectomy/decortication is superior. They noted that no randomized trial compares the two operations and that biases in published series prevent rigorous comparison. Asbestos exposure was not studied.

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: Systematic review of published studies, conducted according to PRISMA guidelines
• Who was studied: 32 published studies (1999 to 2019) of patients with histologically proven malignant pleural mesothelioma treated by EPP, totalling 4369 patients. Only studies with more than 50 EPP patients that reported overall survival were included. Six studies were prospective and 26 retrospective.
• Exposure: Not an asbestos exposure study. The treatment reviewed was extrapleural pneumonectomy, usually combined with chemotherapy and/or radiotherapy given before, during or after surgery.
• Main results:
  • Across included studies, median overall survival ranged from 10.2 months to 46.9 months
  • The text states that overall survival for epithelial mesothelioma ranged from 20.9 months to 51 months. Its Table 1 conflicts with this: it lists 17.1 months for epithelial patients treated with EPP plus heated intraoperative chemotherapy in one study. It also labels the 20.9-month figure as applying to patients younger than 70 with epithelial disease who received chemotherapy.
  • 30-day mortality, reported by 24 studies, ranged from 0% to 11.2%. 90-day mortality, reported by 13 studies, ranged from 3.4% to 17%.
  • Overall morbidity (complication) rate ranged from 21.6% to 73% among the 16 studies reporting it
  • 1064 patients (24.2%) had at least one of the main listed complications. Arrhythmias were the most frequent complication in every study.
  • Overall recurrence rate ranged from 31% to 81%. Most studies reported more distant recurrence (range 10% to 66%) than local recurrence (range 2.3% to 54%).
  • Disease-free survival ranged from 10.6 to 21.6 months
  • In 19 studies reporting it, the rate of completing the intended multimodality treatment had a median of 74% (range 22% to 100%)
• The authors' conclusion: The authors concluded that it is not possible to establish with certainty whether EPP or pleurectomy/decortication is superior. In their view, accurate patient selection and specific expertise are necessary for satisfactory results.
• Limitations the authors state:
  • A rigorous comparison of survival rates is not possible because of biases inherent to published series
  • Treatment protocols differ greatly among centres, making outcomes difficult to compare across the reviewed studies
  • Information on completion of intended treatment is often lacking or unreliable in retrospective series
  • No randomized controlled trial comparing EPP with pleurectomy/decortication exists

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Multimodal Therapy, Pneumonectomy, Pleurectomy/Decortication (P/D), Extrapleural Pneumonectomy (EPP), Systematic Review, Overall Survival, Disease-Free Survival.

Related studies

• A new technique of diaphragmatic patch fixation in extrapleural pneumonectomy — M. Schiavon, A. De Filippis, et al. (2010)
• Accelerated hemithoracic radiation followed by extrapleural pneumonectomy for malignant pleural mesothelioma — M. de Perrot, R. Feld, et al. (2016)
• Extrapleural pneumonectomy for early stage malignant pleural mesothelioma: a harmful procedure — O. Rena, C. Casadio (2012)
• Clinical and pathological features of three-year survivors of malignant pleural mesothelioma following extrapleural pneumonectomy — D.J. Sugarbaker, A.S. Wolf, et al. (2011)
• Extrapleural pneumonectomy for malignant pleural mesothelioma: outcomes of treatment and prognostic factors — T.D. Yan, M. Boyer, et al. (2009)
• Extrapleural pneumonectomy after induction chemotherapy: perioperative outcome in 251 mesothelioma patients from three high-volume institutions — O. Lauk, M.A. Hoda, et al. (2014)

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