Extrapleural pneumonectomy after induction chemotherapy: perioperative outcome in 251 mesothelioma patients from three high-volume institutions

Our plain-English summary of Extrapleural pneumonectomy after induction chemotherapy: perioperative outcome in 251 mesothelioma patients from three high-volume institutions, by O. Lauk, M.A. Hoda, M. de Perrot, et al (The Annals of Thoracic Surgery, 2014).

The study

• Authors: O. Lauk, M.A. Hoda, M. de Perrot, M. Friess, T. Klikovits, W. Klepetko, S. Keshavjee, W. Weder, I. Opitz
• Journal: The Annals of Thoracic Surgery
• Published: 2014;98(5):1748-54
• Type of article: Randomized trial
• Cited by: 39 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Several publications have suggested that induction chemotherapy followed by extrapleural pneumonectomy (EPP) for patients with malignant pleural mesothelioma (MPM) patients is associated with exceedingly high morbidity and mortality, and the role of EPP is controversially debated. The present retrospective study analyzed the perioperative outcome in 251 consecutively treated patients at three high-volume mesothelioma centers.

Methods: 251 MPM patients completed EPP after platinum-based induction chemotherapy at three institutions for thoracic surgery over more than 10 years. The rates of 30-day and 90-day mortality and of major morbidities (pulmonary embolism, postoperative bleeding, acute respiratory distress syndrome, empyema, bronchopleural fistula (BPF), chylothorax, patch failure) were recorded. Perioperative outcome was correlated to risk factors such as smoking history (pack years), age at operation, body mass index, spirometry results, C-reactive protein, American Society of Anesthesiologists classification, chemotherapy regimen used, blood loss during operation, duration of operation, and characteristics of the tumor (laterality, histologic subtype, pT and pN stage) to find factors predicting 30-day and 90-day mortality or major morbidity.

Results: The overall 30-day mortality was 5%. Within 90 days after operation, 8% of the patients died. The rates of 30-day and 90-day mortality were significantly higher in patients with high preoperative C-reactive protein values (p=0.001 and p<0.0005). The spirometry values forced expiratory volume in 1 second and forced vital capacity exhaled (FVCex) were both associated with 30-day and 90-day mortality (p=0.001 and p<0.0005; and p=0.002 and p<0.0005). Major morbidity occurred in 30% of the patients, significantly more often after right-sided EPP (p=0.01) and after longer operations (p<0.0005). Empyema (p<0.0005) and acute respiratory distress syndrome (p=0.02) were associated with longer duration of operation.

Conclusions: EPP after induction chemotherapy is a demanding procedure but can be performed with acceptable morbidity and mortality if patients are well selected and treated at dedicated high-volume MPM centers.

Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

In plain English

This retrospective study looked at what happened around the time of surgery to 251 patients with malignant pleural mesothelioma treated at three centers (Zurich, Toronto and Vienna) between 1999 and 2012. All received platinum-based chemotherapy first, then extrapleural pneumonectomy, an operation removing the lung and the surrounding lining. Asbestos exposure was not studied. Within 30 days of surgery, 12 patients (5%) died, and within 90 days, 21 (8%). Pulmonary embolism was the most frequent cause of death. Patients who died within 30 days had higher C-reactive protein (a blood marker) before surgery and poorer lung-function results than other patients. Major complications occurred in 76 patients (30%), most often empyema (35 patients, 14%). They were more common after right-sided surgery and after longer operations. Early and later years did not differ significantly. The authors concluded that the operation is demanding but can be performed with acceptable complication and death rates if patients are well selected and treated at dedicated high-volume centers. They noted the retrospective design and possible differences between institutions as limitations.

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 patients treated at three institutions
• Who was studied: 251 patients with malignant pleural mesothelioma treated between 1999 and 2012: 137 at the University of Zurich, 60 at the University of Toronto and 54 at the University of Vienna
• Exposure: No asbestos exposure was studied. The treatment studied was platinum-based induction chemotherapy (mostly three cycles), followed within 6 weeks by extrapleural pneumonectomy.
• Main results:
  • Of all 251 patients, 12 (5%) died within 30 days of surgery and 21 (8%) died within 90 days
  • Pulmonary embolism was the most frequent cause of death at all three institutions
  • Patients who died within 30 days had higher preoperative C-reactive protein than other patients (median 53 mg/L, interquartile range 21 to 154, vs 6 mg/L, interquartile range 3 to 22; p = 0.001). A similar difference was found for 90-day mortality.
  • Patients who died within 30 days had lower preoperative lung function: median FEV1 of 51% vs 77% in other patients
  • Major complications occurred in 76 of 251 patients (30%). Empyema affected 35 patients (14%) and bronchopleural fistula affected 20 patients (8%).
  • Major complications were significantly more frequent after right-sided surgery (p = 0.01). Bronchopleural fistula occurred only once after left-sided surgery.
  • Patients with major complications had longer operations (median 398 minutes vs 320 minutes; p less than 0.0005)
  • Complication and death rates did not differ significantly between the earlier period (1999 to 2005) and the later period (2006 to 2013)
• The authors' conclusion: The authors concluded that extrapleural pneumonectomy after induction chemotherapy is a demanding procedure but can be performed with acceptable morbidity and mortality if patients are well selected and treated at dedicated high-volume mesothelioma centers
• Limitations the authors state:
  • The analysis was retrospective
  • Postoperative care was not identical at the three centers, so there may be institutional bias
  • Comparison with other reports is difficult because definitions of major morbidity vary

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: Extrapleural Pneumonectomy (EPP), Chemotherapy, Mesothelioma, Pleural Mesothelioma, Thoracic Surgery, Empyema, Spirometry, Histological Subtype.

Related studies

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• PI3K/mTOR signaling in mesothelioma patients treated with induction chemotherapy followed by extrapleural pneumonectomy — B.K. Bitanihirwe, M. Meerang, et al. (2014)
• Impact of induction therapy on postoperative outcome after extrapleural pneumonectomy for malignant pleural mesothelioma: does induction-accelerated hemithoracic radiation increase the surgical risk? — P. Mordant, K. McRae, et al. (2016)
• Induction chemotherapy, extrapleural pneumonectomy, and adjuvant radiotherapy for malignant pleural mesothelioma: experience of Guy's and St Thomas' hospitals — A. Bille, E. Belcher, et al. (2012)
• Hemithoracic radiation therapy after extrapleural pneumonectomy for malignant pleural mesothelioma: Toxicity and outcomes at an Australian institution — A. Bece, M.M. Tin, et al. (2015)
• Intrathoracic chemo-thermotherapy with radiofrequency waves after extrapleural pneumonectomy for malignant pleural mesothelioma — T. Tokunaga, M. Higashiyama, et al. (2011)

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