Extrapleural pneumonectomy or supportive care: treatment of malignant pleural mesothelioma?

Our plain-English summary of Extrapleural pneumonectomy or supportive care: treatment of malignant pleural mesothelioma?, by S. Sharif, I. Zahid, T. Routledge, et al (Interactive Cardiovascular and Thoracic Surgery, 2011).

The study

• Authors: S. Sharif, I. Zahid, T. Routledge, M. Scarci
• Journal: Interactive Cardiovascular and Thoracic Surgery
• Published: 2011;12(6):1040-5
• Type of article: Review
• Cited by: 12 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether extrapleural pneumonectomy (EPP) is superior to supportive care in the treatment of patients with malignant pleural mesothelioma (MPM). Overall, 110 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that EPP confers no advantage to chemotherapy and palliative treatment in terms of survival and symptom improvement. Ten studies evaluated the role of EPP in the management of MPM. The median survival was 13 months and perioperative and 30-day mortality rates were 5.7% and 9.1%, respectively. There was a high morbidity rate of 37% including atrial fibrillation, empyema and supraventricular arrhythmias. Disease recurred in 73% of patients at a median time of 10 months. Median hospital stay was 13 days and intensive care unit stay was 1.5 days. At three months postsurgery, improvement in symptoms was achieved in 68% of patients. Significant advantages were observed in patients with epithelial MPM (19 vs. 8 months, P<0.01) compared to non-epithelial MPM and with N2 disease (19 vs. 10 months) compared to N1 or N0 disease, respectively. Two studies reported outcomes after chemotherapy in patients with MPM. The median survival was 13 months and symptoms improved in 50% of patients. Response rate of 21% was achieved and the median time to disease progression was 7.2 months. Postoperative haematological toxicity was common and included neutropenia (25%), anaemia (5%) and thrombocytopenia (7.4%). Two studies analysed palliative treatment in mesothelioma and reported a median survival of seven months and improvement in symptoms in 25% of patients at one-year post-treatment. The 30-day mortality rate was 7.8% and complications included prolonged air leak (9.8%) and empyema (4%). Median hospital stay was seven days. Overall, EPP shows no benefit in terms of survival or symptom improvement which is compounded by its high operative mortality and recurrence rate.

In plain English

This article was a 'best evidence topic', a structured literature review. It asked whether extrapleural pneumonectomy (EPP) is better than supportive care for malignant pleural mesothelioma, judged by complications, symptom control and survival. A Medline search found 110 papers, and the authors selected 14: ten on EPP, two on chemotherapy and two on palliative surgery. Median survival in the EPP studies ranged from 12 to 29 months. The 29 months and a 53% complication rate came from 15 patients also given postoperative hemithoracic radiation. Initial results from the MARS randomised trial's feasibility phase showed 12-month survival of 52.2% (95% confidence interval 30.5 to 70.0) among 24 EPP patients versus 73.1% (51.7 to 86.2) among 26 without EPP. Its hazard ratio was 2.75 (95% confidence interval 1.21 to 6.26) in favour of no EPP. The two chemotherapy studies reported median survival of 13 and 16.8 months. A palliative surgery study of 51 patients reported median survival of seven months. The authors concluded EPP is a highly morbid operation with high perioperative mortality and recurrence rate. The article does not discuss asbestos exposure.

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: Best evidence topic: a structured literature review of published studies (Medline search) that selected the best evidence for a clinical question
• Who was studied: 14 published papers, out of 110 found in a Medline search from 1950 to August 2010, on patients with malignant pleural mesothelioma: ten on EPP, two on chemotherapy and two on palliative treatment
• Exposure: No asbestos or fiber exposure was studied. The 'exposures' compared were treatments: extrapleural pneumonectomy (EPP) versus supportive care (chemotherapy or palliative surgery)
• Main results:
  • MARS trial, initial results of the feasibility phase (randomised; EPP n=24 vs no EPP n=26): 12-month survival was 52.2% (95% CI 30.5 to 70.0) with EPP vs 73.1% (95% CI 51.7 to 86.2) without
  • MARS feasibility phase: perioperative mortality was 12.5% with EPP vs 3.8% without, and the hazard ratio was 2.75 (95% CI 1.21 to 6.26, P=0.02) in favour of no EPP
  • Aziz et al. (retrospective cohort): EPP patients had major complication and 30-day mortality rates of 21% and 9.1%; median survival was 13 months with EPP vs 7 months with supportive care
  • Ambrogi et al. (16 EPP patients): median survival was 13 months; patients with non-epithelial mesothelioma (8 vs 19 months, P less than 0.01) and with N2 disease (10 vs 19 months) had shorter survival than those with epithelial mesothelioma and N0 or N1 disease
  • Flores et al.: median survival of 12 months in EPP patients, with operative mortality of 7%
  • Yan et al. (70 EPP patients): median survival was 20 months; perioperative mortality was 5.7% and the complication rate was 37%
  • Van Sandick et al. (15 patients given EPP plus postoperative hemithoracic radiation): median survival was 29 months, the complication rate was 53%, and disease recurred in 73%
  • Chemotherapy: Sørensen et al. (54 patients with inoperable mesothelioma, cisplatin and vinorelbine) reported median survival of 16.8 months; Pinto et al. reported median survival of 13 months
  • Palliative surgery: Martin-Ucar et al. (51 patients, palliative surgical debulking) reported median survival of seven months; symptoms improved in 78.4% at three months but in 25.5% at one year
• The authors' conclusion: The authors concluded that EPP is a highly morbid operation with high perioperative mortality and recurrence rate. They said great weight should be given to the initial MARS trial findings showing detrimental effects of EPP compared with conservative management.

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, Thoracic Surgery, Chemotherapy, Palliative Care, Median Survival, Empyema, Disease Progression.

Related studies

• Is pleurectomy and decortication superior to palliative care in the treatment of malignant pleural mesothelioma? — I. Zahid, S. Sharif, et al. (2011)
• Staging of patients after extrapleural pneumonectomy for malignant pleural mesothelioma--institutional review and current update — C. Cao, S.K. Krog Andvik, 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 Is Not Shown to Be Clinically Effective in the Treatment of Malignant Pleural Mesothelioma — G. Cardillo, T. Treasure (2017)
• Summary of prognostic factors and patient selection for extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma — C. Cao, T.D. Yan, et al. (2011)
• What is the optimum strategy for thromboembolic prophylaxis following extrapleural pneumonectomy in patients with malignant pleural mesothelioma? — A. Billè, L. Okiror, et al. (2012)

Browse more research in Interactive Cardiovascular and Thoracic Surgery, or return to medical research.