Extrapleural pneumonectomy for malignant mesothelioma: an Italian multicenter retrospective study

Our plain-English summary of Extrapleural pneumonectomy for malignant mesothelioma: an Italian multicenter retrospective study, by L. Spaggiari, G. Marulli, P. Bovolato, et al (The Annals of Thoracic Surgery, 2014).

The study

• Authors: L. Spaggiari, G. Marulli, P. Bovolato, M. Alloisio, V. Pagan, A. Oliaro, G.B. Ratto, F. Facciolo, R. Sacco, D. Brambilla, P. Maisonneuve, F. Mucilli, G. Alessandrini, G. Leoncini, E. Ruffini, P. Fontana, M. Infante, G.L. Pariscenti, M. Casiraghi, F. Rea
• Journal: The Annals of Thoracic Surgery
• Published: 2014;97(6):1859-65
• Cited by: 35 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: This study assessed perioperative outcome and long-term survival in a large series of patients with malignant pleural mesothelioma who underwent extrapleural pneumonectomy (EPP) to identify prognostic factors allowing better patient selection.

Methods: We retrospectively collected data from nine referral centers for thoracic surgery in Italy. Perioperative outcome and survival data were available for 518 malignant pleural mesothelioma patients (84.4% with epithelial tumors, 68.0% with pathologic stage 3 disease) who underwent EPP with intention-to-treat (R0/R1) between 2000 and 2010. Induction chemotherapy was administered in 271 patients (52.3%) and adjuvant therapy in 373 patients (72.0%), including radiotherapy in 213 patients (41.1%), adjuvant chemotherapy in 43 patients (8.3%), and both in 117 patients (22.6%).

Results: In all, 136 patients (26.3%) had major complications after EPP, and 36 (6.9%) died within 90 days after surgery. The median overall survival was 18 months, with a 1-, 2-, and 3-year overall survival of 65%, 41%, and 27%, respectively. At multivariable analysis adjusted for age and disease stage, male sex (hazard ratio [HR] 1.47, 95% confidence interval [CI]: 1.12 to 1.92), nonepithelial histology (HR 1.96, 95% CI: 1.48 to 2.58), and trimodality treatment using induction chemotherapy (HR 0.61, 95% CI: 0.43 to 0.85) were significantly associated with survival. Development of a major complication also significantly worsened outcome (HR 1.85, 95% CI: 1.37 to 2.50).

Conclusions: The success of EPP in the context of a multimodality treatment depends on a series of patient characteristics. Female patients, patients with epithelial tumors, and patients who received induction chemotherapy will best benefit from EPP.

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

In plain English

This Italian study looked back at patients with malignant pleural mesothelioma who had extrapleural pneumonectomy (EPP). EPP is an operation that removes the lung, chest lining, pericardium and diaphragm. Nine referral centers pooled records on 518 patients treated from 2000 to 2010. Most had epithelial tumors (84.4%) and stage 3 disease (68.0%). Major complications occurred in 136 patients (26.3%), and 36 (6.9%) died within 90 days of surgery. Median overall survival was 18 months; 65%, 41% and 27% were alive at 1, 2 and 3 years. In the adjusted analysis, shorter survival was linked to male sex (hazard ratio 1.47, 95% confidence interval 1.12 to 1.92), non-epithelial tumors (1.96, 1.48 to 2.58) and a major complication (1.85, 1.37 to 2.50). Chemotherapy before surgery, then EPP, then radiotherapy (trimodality treatment) was linked to longer survival than EPP followed by radiotherapy without prior chemotherapy (0.61, 0.43 to 0.85). The authors concluded that women, patients with epithelial tumors and those given induction chemotherapy benefit most from EPP. They noted its retrospective design and imprecise data on other illnesses.

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 multicenter study of surgical outcomes and survival
• Who was studied: Patients with malignant pleural mesothelioma at nine Italian thoracic surgery referral centers, 2000 to 2010. There were 573 candidates. The authors excluded 46 who had only exploratory thoracotomy and 9 lost to follow-up. That left 518 analyzed (median age 61 years, range 31 to 78).
• Exposure: The study examined treatment, not asbestos. All patients had extrapleural pneumonectomy, with or without induction chemotherapy and adjuvant radiotherapy or chemotherapy. Asbestos exposure was listed among the variables tested, but no result for it is reported.
• Main results:
  • Major complications after EPP occurred in 136 patients (26.3%).
  • 36 patients (6.9%) died within 90 days after surgery.
  • For all 518 patients, median overall survival was 18 months. Overall survival was 65% at 1 year, 41% at 2 years and 27% at 3 years.
  • In multivariable analysis, men had worse survival than women (HR 1.47, 95% CI 1.12 to 1.92).
  • In multivariable analysis, nonepithelial histology was associated with worse survival than epithelial histology (HR 1.96, 95% CI 1.48 to 2.58).
  • In multivariable analysis, trimodality treatment was associated with better survival (HR 0.61, 95% CI 0.43 to 0.85). Trimodality treatment meant induction chemotherapy, then surgery, then adjuvant radiotherapy, and 185 patients (35.7%) completed it. The comparison group had surgery followed by radiotherapy without induction chemotherapy.
  • Development of a major complication was associated with worse survival than no major complication (HR 1.85, 95% CI 1.37 to 2.50).
  • Pathologic N2 lymph node involvement was associated with a worse outcome.
• The authors' conclusion: The authors concluded that the success of EPP within multimodality treatment depends on patient characteristics. In their view, female patients, patients with epithelial tumors and patients who received induction chemotherapy will best benefit from EPP.
• Limitations the authors state:
  • The study failed to collect precise comorbidity data.
  • The authors called the retrospective design an important bias that probably limited and influenced all variables analyzed.

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), Malignant Mesothelioma, Pleural Mesothelioma, Thoracic Surgery, Chemotherapy, Adjuvant Therapy, Median Overall Survival, Overall Survival.

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• Epithelial malignant pleural mesothelioma after extrapleural pneumonectomy: stratification of survival with CT-derived tumor volume — R.R. Gill, W.G. Richards, et al. (2012)
• A new technique of diaphragmatic patch fixation in extrapleural pneumonectomy — M. Schiavon, A. De Filippis, 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)
• Extrapleural pneumonectomy in the treatment of epithelioid malignant pleural mesothelioma: novel prognostic implications of combined N1 and N2 nodal involvement based on experience in 529 patients — D.J. Sugarbaker, W.G. Richards, et al. (2014)

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