Extrapleural pneumonectomy for diffuse, malignant mesothelioma

Our plain-English summary of Extrapleural pneumonectomy for diffuse, malignant mesothelioma, by M.J. DaValle, L.P. Faber, C.F. Kittle, et al (The Annals of Thoracic Surgery, 1986).

The study

• Authors: M.J. DaValle, L.P. Faber, C.F. Kittle, R.J. Jensik
• Journal: The Annals of Thoracic Surgery
• Published: 1986;42(6):612-8
• Cited by: 71 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Extrapleural pneumonectomy for malignant mesothelioma is a radical procedure that entails en bloc removal of the parietal pleura, lung, pericardium, and diaphragm. Minimal tumor remains after this procedure; palliation and occasional long-term survival may be achieved in properly selected patients. Extrapleural pneumonectomy for diffuse, malignant mesothelioma was done in 33 patients (27 male and 6 female) with 18 procedures on the left side and 15 on the right. There was a history of exposure to asbestos in 16 (48%) of the patients. Histological classification revealed that 20 tumors were epithelial, 10 were mixed, and 3 were sarcomatous. Good palliation, defined as survival for 24 months with a return to fairly normal activities, was obtained in 8 patients (24%) and survival for 36 months was achieved in 5 patients. Three patients died of the disease at 59 months, 60 months, and 82 months. There were 3 operative deaths (9.1%), and serious postoperative complications occurred in 8 patients (24%). Postoperative adjunctive therapy consisting of chemotherapy or irradiation or both was given to approximately one-half of the patients. These findings indicate that extrapleural pneumonectomy for malignant mesothelioma can be done with an acceptable morbidity and mortality. Palliation is achieved in 24% of patients, and there may be an occasional long-term survivor.

In plain English

This article reviewed one Chicago medical center's experience with extrapleural pneumonectomy for diffuse malignant mesothelioma. The operation removes the lining of the chest wall, the lung, the sac around the heart and the diaphragm together. Between 1958 and 1985, 33 patients had the operation: 27 men and 6 women, with an average age of 55. Of these, 16 (48%) had been exposed to asbestos, either directly or through a family member. Twenty tumors were epithelial, 10 mixed and 3 sarcomatous. Three patients (9.1%) died after surgery, and 8 (24%) had major complications. By life-table analysis, survival at one, two, three and five years was 48%, 24%, 15% and 6%, and median survival was 13.3 months. Differences in survival between tumor types were not statistically significant. The 17 patients given added chemotherapy or radiation had an average survival of 17.5 months. This was no better than the 21.7 months of the 13 patients who survived surgery without it. The authors concluded the operation could be done in selected patients with low mortality and acceptable complications, but they did not recommend it as the procedure of choice.

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 one institution's surgical case series
• Who was studied: 33 patients (27 men, 6 women; average age 55, range 32 to 68) with diffuse malignant mesothelioma confined to the chest but extending to the visceral pleura or diaphragm. All had extrapleural pneumonectomy at Rush-Presbyterian-St. Luke's Medical Center, Chicago, out of 56 patients operated on for the disease from 1958 through 1985. The other 23 had pleurectomy only.
• Exposure: This is a study of a surgical treatment, not of exposure. The article reports that 16 of the 33 patients (48%) had been exposed to asbestos fibers, either directly or through close association with a family member. Fiber types and jobs were not given.
• Main results:
  • Among the 33 extrapleural pneumonectomy patients there were 3 operative deaths (9.1%). Causes were bleeding in 1 patient, pulmonary embolism in 1 and myocardial infarction in 1.
  • Major complications occurred in 8 of the 33 patients (24%). They included bronchopleural fistula (2), left vocal cord paralysis (2), chylothorax (1), contralateral pleural effusion (1), refractory cardiac arrhythmia (1) and respiratory failure requiring tracheostomy (1).
  • Tumor types: 20 epithelial, 3 sarcomatous, 10 mixed cell.
  • Life-table survival for all 33 patients was 48% at one year, 24% at two years, 15% at three years and 6% at five years.
  • Median survival was 13.3 months for all patients and 13.5 months for the epithelial type. Average survival was 17.8 months for all patients and 20.6 months for the epithelial type.
  • Survival differences among the three tumor types were not statistically significant.
  • The 17 patients (52%) given adjunctive therapy (Adriamycin alone or with other agents or irradiation) had an average survival of 17.5 months. This was no better than the 21.7 months of the 13 patients who survived operation without adjunctive therapy.
  • Three patients died of the disease at 59, 60 and 82 months.
  • In the same institution's 23 pleurectomy-only patients there were 3 operative deaths (13%). Their average age was 65 and median survival was 11.2 months.
• The authors' conclusion: The authors stated they were not recommending extrapleural pneumonectomy as the surgical procedure of choice for malignant mesothelioma. Their aim was to show it can be done in selected patients with low mortality and an acceptable rate of manageable complications.
• Limitations the authors state:
  • The authors noted drawbacks of the surgical approach: tumor recurrence in the incision, and the possibility that the operation's complications and deaths could shorten life.
  • The authors noted that surgical results must be compared with chemotherapy and irradiation alone, which do not carry the operation's mortality.

Topics

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

Medical terms in this study, explained in our Lexicon: Extrapleural Pneumonectomy (EPP), Malignant Mesothelioma, Parietal Pleura, Pericardium, Diaphragm, Histological Subtype, Chemotherapy.

Related studies

• A new technique of diaphragmatic patch fixation in extrapleural pneumonectomy — M. Schiavon, A. De Filippis, et al. (2010)
• Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma — E. Taioli, A.S. Wolf, et al. (2015)
• Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma — S. Hasegawa (2014)
• Extrapleural Pneumonectomy Versus Pleurectomy/Decortication for Malignant Pleural Mesothelioma — N. Zhou, D.C. Rice, et al. (2022)
• Current Treatment of Mesothelioma: Extrapleural Pneumonectomy Versus Pleurectomy/Decortication — A.S. Wolf, R.M. Flores (2016)
• Short-term outcomes of pleurectomy decortication and extrapleural pneumonectomy in mesothelioma — M. van Gerwen, A. Wolf, et al. (2018)

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