Extrapleural Pneumonectomy Versus Pleurectomy/Decortication for Malignant Pleural Mesothelioma

Our plain-English summary of Extrapleural Pneumonectomy Versus Pleurectomy/Decortication for Malignant Pleural Mesothelioma, by N. Zhou, D.C. Rice, A.S. Tsao, et al (The Annals of Thoracic Surgery, 2022).

The study

• Authors: N. Zhou, D.C. Rice, A.S. Tsao, P.P. Lee, C.L. Haymaker, E.M. Corsini, M.B. Antonoff, W.L. Hofstetter, R. Rajaram, J.A. Roth, S.G. Swisher, A.A. Vaporciyan, G.L. Walsh, R.J. Mehran, B. Sepesi
• Journal: The Annals of Thoracic Surgery
• Published: 2022;113(1):200-208
• Cited by: 31 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Whether extrapleural pneumonectomy (EPP) or extended pleurectomy/decortication (P/D) is the optimal resection for malignant pleural mesothelioma remains controversial. We therefore compared perioperative outcomes and long-term survival of patients who underwent EPP versus P/D.

Methods: Patients with the diagnosis of malignant pleural mesothelioma who underwent either EPP or P/D from 2000 to 2019 were identified from our departmental database. Propensity score matching was performed to minimize potential confounders for EPP or P/D. Survival analysis was performed by the Kaplan-Meier method and Cox multivariable analysis.

Results: Of 282 patients, 187 (66%) underwent EPP and 95 (34%) P/D. Even with propensity score matching, perioperative mortality was significantly higher for EPP than for P/D (11% vs 0%; P = .031); when adjusted for perioperative mortality, median overall survival between EPP and P/D was 15 versus 22 months, respectively (P = .276). Cox multivariable analysis for the matched cohort identified epithelioid histology (hazard ratio [HR], 0.56; P = .029), macroscopic complete resection (HR, 0.41; P = .004), adjuvant radiation therapy (HR, 0.57; P = .019), and more recent operative years (HR, 0.93; P = .011)-but not P/D-to be associated with better survival. Asbestos exposure (HR, 2.35; P = .003) and pathologic nodal disease (HR, 1.61; P = .048) were associated with worse survival.

Conclusions: In a multimodality treatment setting, P/D and EPP had comparable long-term oncologic outcomes, although P/D had much lower perioperative mortality. The goal of surgical cytoreduction should be macroscopic complete resection achieved by the safest operation a patient can tolerate.

Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

In plain English

This study reviewed 282 adults operated on for malignant pleural mesothelioma at MD Anderson Cancer Center, Texas, from 2000 to 2019. It compared extrapleural pneumonectomy (EPP, lung removed; 187 patients) with pleurectomy/decortication (P/D, lung spared; 95 patients). The authors matched 57 comparable patients from each group. In the matched groups, 6 EPP patients (11%) and no P/D patients died around surgery. Excluding those deaths, median survival was 15 months (95% CI 9 to 21) after EPP and 22 months (95% CI 16 to 28) after P/D. This was not statistically significant, though the authors called it clinically meaningful. In a statistical model, operation type was not linked to survival. Asbestos exposure was associated with shorter survival (hazard ratio 2.35, 95% CI 1.33 to 4.15), as was lymph node cancer (hazard ratio 1.61, 95% CI 1.00 to 2.57). Epithelioid tumors, removal of all visible tumor, post-surgery radiation and more recent operation years were associated with longer survival. The authors concluded long-term outcomes were comparable but P/D had lower perioperative mortality. They noted the retrospective design and limited sample size.

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 single-institution study using a prospectively maintained departmental database, with propensity score matching of the two surgical groups
• Who was studied: 282 patients aged 18 or older with malignant pleural mesothelioma who underwent cytoreductive surgery at The University of Texas MD Anderson Cancer Center (Houston, Texas) from January 1, 2000, to June 30, 2019. 187 had EPP and 95 had P/D. The matched analysis included 57 patients per group (114 total).
• Exposure: The study compared two operations, extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). Asbestos exposure was recorded as a patient characteristic and tested as a factor in survival. The article does not describe fiber types, sources, jobs or doses.
• Main results:
  • All 282 patients, before matching and with no adjustment: median overall survival was 11 months (95% CI 8 to 14) after EPP and 18 months (95% CI 12 to 23) after P/D (P = 0.005).
  • All patients, before matching: perioperative mortality was 21 of 187 (11.2%) after EPP and 0 of 95 after P/D. Causes of the 21 EPP deaths included cardiac arrest (7), respiratory failure (6) and infection (5).
  • Matched cohort: perioperative mortality was 6 (11%) after EPP and 0 after P/D (P = 0.031).
  • Matched cohort, excluding perioperative deaths: median overall survival was 15 months (95% CI 9 to 21) after EPP and 22 months (95% CI 16 to 28) after P/D (P = 0.276). The authors described this difference as clinically meaningful.
  • Matched cohort: 5-year overall survival was 13% (95% CI 6% to 33%) after EPP and 25% (95% CI 15% to 42%) after P/D.
  • Cox multivariable analysis of the matched cohort (114 patients): asbestos exposure was associated with shorter overall survival (HR 2.35, 95% CI 1.33 to 4.15, P = 0.003).
  • Same model, matched cohort: pathological nodal disease was associated with shorter overall survival (HR 1.61, 95% CI 1.00 to 2.57, P = 0.048).
  • Same model, matched cohort: factors associated with longer overall survival were epithelioid histology (HR 0.56, 95% CI 0.34 to 0.94), macroscopic complete resection (HR 0.41, 95% CI 0.22 to 0.75), adjuvant radiation (HR 0.57, 95% CI 0.36 to 0.91) and more recent year of operation (HR 0.93, 95% CI 0.88 to 0.98). Type of operation was not associated with survival (P/D HR 0.75, 95% CI 0.47 to 1.20, P = 0.230).
  • Recurrence: before matching, local recurrence was more frequent after P/D (54%) than after EPP (28%). In the matched cohort there was no difference in total, local, regional or distant recurrence.
• The authors' conclusion: The authors concluded that both operations can achieve maximum cytoreduction, but P/D has a lower risk of perioperative death, and they found no oncological benefit of either approach over the other. In their view, the goal should be removal of all visible tumor by the safest operation the patient can tolerate.
• Limitations the authors state:
  • The study was retrospective and spanned a long period, so unknown confounding factors, changes in treatment and changes in patient selection over time may have affected results.
  • Propensity score matching was used to reduce confounding but itself carries a risk of bias and overfitting.
  • The sample may have been too small to detect real differences (possible type II error).
  • The authors acknowledged that the 7 to 9 month difference in median survival between EPP and P/D is clinically meaningful and may warrant further study.

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), Pleurectomy/Decortication (P/D), Pleural Mesothelioma, Median Overall Survival, Epithelioid, Histology, Hazard Ratio, Asbestos Exposure.

Related studies

• Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma — E. Taioli, A.S. Wolf, et al. (2015)
• 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)
• Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma — S. Hasegawa (2014)
• Extrapleural Pneumonectomy and Pleurectomy Decortication: Can We Really Compare Their Survival? — P. Bertoglio, S. Korasidis (2015)
• Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma — L. Lang-Lazdunski, A. Bille, et al. (2012)

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