Extrapleural pneumonectomy for early stage malignant pleural mesothelioma: a harmful procedure

Our plain-English summary of Extrapleural pneumonectomy for early stage malignant pleural mesothelioma: a harmful procedure, by O. Rena, C. Casadio (Lung Cancer, 2012).

The study

• Authors: O. Rena, C. Casadio
• Journal: Lung Cancer
• Published: 2012;77(1):151-5
• Cited by: 80 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

The effects on long-term post-operative quality of life (QoL) and disease-control in malignant pleural mesothelioma (MPM) of extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D) are compared. Seventy-seven patients affected by early-stage MPM received EPP (40) or P/D (37) associated with multimodal treatment between 1998 and 2009 at our institution. The last consecutive 39 (19 EPP and 20 P/D) were asked to answer the EORTC-QLQ-C30 questionnaire at baseline and at 6- and 12-months after treatment completion to evaluate the impact on QoL of both procedures. QoL evaluation was stopped at recurrence demonstration. Twenty-five (62%) EPP vs 9 (24%) P/D patients (p = 0.002) had in-hospital major complications, and 2/40 (5%) EPP vs no one P/D patients died after surgery. Both procedures caused a significant impairment of all the considered variables of the EORTC-QLQ-C30 questionnaire after treatment completion; only P/D patients returned at baseline levels after 12 months. EPP patients had a worse long-term post-operative QoL when compared with P/D. Median post-operative disease-free period was longer for EPP patients (14 vs 11 months) whereas the residual life to death period after recurrence detection was significantly longer for P/D patients (13 vs 9 months) (p = 0.01). Median long-term survival was longer, even not significant, for P/D patients (25 vs 20 months). MPM patients submitted to EPP had a higher post-operative complication rate, a worse long-term QoL, a shorter residual life time after recurrent disease, despite a similar long-term survival when compared to P/D.

Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

In plain English

This study, from a thoracic surgery unit in Novara, Italy, compared two operations for early-stage (stage I or II) malignant pleural mesothelioma. Each was combined with platinum-based chemotherapy and radiation. Between 1998 and 2009, 40 patients had extrapleural pneumonectomy (EPP), which removes the lung, and 37 had pleurectomy/decortication (P/D), which spares it. Patients were not randomly assigned. In hospital, complications occurred in 25 of 40 EPP patients (62%) and 9 of 37 P/D patients (24%). Two EPP patients died after surgery; no P/D patients did. Recurrence confined to the chest was more common after P/D (56% versus 21%). After recurrence, median survival was 14 months for P/D and 9 months for EPP. Overall survival was longer after P/D, but the difference was not statistically significant. Among patients who completed quality-of-life questionnaires before any recurrence, the P/D group reported better quality of life at 6 and 12 months. The authors concluded that the study suggests P/D has lower morbidity and mortality than EPP. They named the lack of randomisation and the single-institution setting 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: prospective non-randomised comparison of two surgical procedures at a single institution
• Who was studied: 77 patients with pathologically confirmed early-stage malignant pleural mesothelioma (16 stage I, 61 stage II), drawn from 423 patients diagnosed by thoracoscopic pleural biopsy at the Thoracic Surgery Unit in Novara, Italy, between January 1998 and December 2009. 40 had EPP and 37 had P/D. Quality-of-life questionnaires were given to 39 patients (19 EPP, 20 P/D) treated from January 2002.
• Exposure: Two treatments were compared. EPP was combined with platinum-based chemotherapy and radiation of the entire hemithorax (45 to 60 Gy). P/D was combined with platinum-based chemotherapy and radiation of the surgical incisions (21 Gy). Asbestos exposure was recorded only as a patient characteristic.
• Main results:
  • In-hospital postoperative complications occurred in 25 of 40 EPP patients (62%).
  • In-hospital postoperative complications occurred in 9 of 37 P/D patients (24%). The difference from the EPP group was significant (p = 0.002).
  • Two EPP patients (5%) died on postoperative days 12 and 14. No P/D patients died.
  • Purely local recurrence was significantly more frequent in the P/D group than in the EPP group (21% EPP vs 56% P/D; p = 0.04).
  • Median residual time to death after recurrence was significantly shorter for EPP than for P/D patients (median 9 vs 14 months; p = 0.001).
  • Long-term survival was longer for P/D than for EPP, but the difference was not statistically significant (p = 0.098).
  • 34 of 38 EPP patients (89%) who survived surgery died during the observation period, from recurrent MPM or from complications of therapy.
  • Among disease-free patients who completed questionnaires, P/D patients reported better quality of life than EPP patients at 6 and 12 months, despite similar baseline scores.
  • In P/D patients, physical and social function returned to levels similar to baseline at 12 months.
  • In EPP patients, the other quality-of-life parameters measured remained significantly impaired 12 months after surgery.
• The authors' conclusion: The authors concluded that, although the study was not randomised, it suggests P/D within a multimodal protocol has lower morbidity and mortality than EPP. They also concluded it gives better quality of life up to recurrence and longer survival after recurrence.
• Limitations the authors state:
  • The series was not randomised. The authors attribute this to the rarity of the disease and the study's single-institution character.

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), Pleural Mesothelioma, Quality of Life, Pleurectomy/Decortication (P/D).

Related studies

• Second surgery for recurrence of malignant pleural mesothelioma after extrapleural pneumonectomy — L. Politi, G. Borzellino (2010)
• High-dose-rate surface brachytherapy to boost elongated, curvilinear incisional scars after extrapleural pneumonectomy for malignant pleural mesothelioma treated with adjuvant intensity-modulated radiation therapy — L.A. Doyle, T.N. Showalter, et al. (2010)
• Patterns of failure, toxicity, and survival after extrapleural pneumonectomy and hemithoracic intensity-modulated radiation therapy for malignant pleural mesothelioma — D.R. Gomez, D.S. Hong, et al. (2013)
• Malignant pleural mesothelioma: clinicopathology of 16 extrapleural pneumonectomy patients with special reference to early stage features — K. Hiroshima, T. Yusa, et al. (2009)
• Clinical impact of extrapleural pneumonectomy for malignant pleural mesothelioma — V. Ambrogi, A. Baldi, et al. (2012)
• Accelerated hemithoracic radiation followed by extrapleural pneumonectomy for malignant pleural mesothelioma — M. de Perrot, R. Feld, et al. (2016)

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