Factors predicting poor survival after lung-sparing radical pleurectomy of IMIG stage III malignant pleural mesothelioma

Our plain-English summary of Factors predicting poor survival after lung-sparing radical pleurectomy of IMIG stage III malignant pleural mesothelioma, by S. Bölükbas, M. Eberlein, N. Kudelin, et al (European Journal of Cardio-thoracic Surgery, 2013).

The study

• Authors: S. Bölükbas, M. Eberlein, N. Kudelin, M. Demes, S. Stallmann, A. Fisseler-Eckhoff, J. Schirren
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2013;44(1):119-23
• Cited by: 23 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objectives: The role of radical pleurectomy (RP) in the management of IMIG stage III in malignant pleural mesothelioma (MPM) remains controversial. The aim of the study was to investigate the feasibility and outcome as well as to determine factors predicting poor survival.

Methods: Patients having IMIG stage III MPM were identified within a prospective multimodality treatment study (RP followed by chemoradiation) between 2002 and 2010 at a single institution. Kaplan-Meier analyses, log-rank test and Cox regression analyses were used to estimate survival and to determine predictors of survival.

Results: A total of 78 patients (66.3 ± 2.5 years, 65 males) underwent RP followed by chemoradiation. A total of 42 (54%) had IMIG stage III. Mortality and morbidity were 4.8 and 31%, respectively. Median survival and 5-year survival were 21 months and 28%, respectively, for stage III patients. Progression-free survival was 11 months. The sites of failure were predominantly locoregional (20/42, 47.6%). Pathological detection of tumour spread at the resected thoracoscopy incisions (median survival 12 vs 35 months, P < 0.001), incomplete resections (median survival 13 vs 35 months, P = 0.01) and male gender (median survival 18 vs 68 months, P < 0.039) were associated with inferior survival in the univariate analyses. Histology, lymph node metastases, laterality and age had no significant impact on survival. The tumour spread at the resected previous incisions remained the only significant prognostic factor (hazard ratio (HR) = 4.3; P = 0.027) in the multivariate analysis. Patients having tumour spread had survival comparable to that of patients at stage IV in the complete patient cohort (median survival 12 vs 8 months; P = 0.39).

Conclusions: Lung-sparing RP for IMIG stage III MPM is feasible and offers promising long-term survival. The tumour spread at the resected previous incisions is associated with more incomplete resections and was a negative prognosticator for long-term survival. The tumour spread at the resected previous incisions or chest tube sites should be considered as T4 or stage IV according to the IMIG staging system.

In plain English

This German single-hospital study examined patients with malignant pleural mesothelioma treated between 2002 and 2010 by radical pleurectomy, removing the lung lining but keeping the lung. Cisplatin/pemetrexed chemotherapy and chest-wall radiation were planned afterwards. Of 78 patients, the authors retrospectively analysed the 42 with IMIG stage III disease; 39 started chemotherapy and 36 completed all treatment. Asbestos exposure is not reported. In stage III, 4.8% died soon after surgery; 31% had complications. Median survival was 21 months (95% confidence interval 5.6 to 36.7); 28% survived 5 years. Tumour at earlier incision sites was the only factor significant in multivariate analysis (hazard ratio 4.3). The 29 such patients had median survival of 12 months (interval 5.3 to 19.3) versus 35 (16.4 to 53.6) for the 13 without, comparable to stage IV (8 months). Disease returned in the chest only in 20 of 42, distantly only in 6, and both in 6. The authors concluded the surgery is feasible and proposed that such incision-site tumour should be considered T4 or stage IV. They noted the small single-centre sample and no control group.

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 analysis of patients within a prospective single-institution multimodality treatment study (radical pleurectomy followed by chemoradiation); no control group
• Who was studied: 42 patients with IMIG stage III malignant pleural mesothelioma, out of 78 patients (mean age 66.3 years, 65 males) treated at one institution (Dr.-Horst-Schmidt-Klinik, Wiesbaden, Germany) between 2002 and 2010
• Exposure: No asbestos exposure is reported. The study concerned treatment: lung-sparing radical pleurectomy (removal of visceral and parietal pleura), with four cycles of cisplatin/pemetrexed and radiation of the chest wall planned afterwards
• Main results:
  • Of the 42 stage III patients, 39 (93%) proceeded to adjuvant chemotherapy and 36 (86%) completed the trimodality therapy
  • Stage III patients: operative mortality 4.8% and morbidity 31%
  • Stage III patients: median survival 21 months (95% CI 5.6 to 36.7)
  • Stage III patients: 1-, 3- and 5-year survival 86%, 37% and 28%
  • Tumour spread at resected previous incisions was the only significant prognostic factor in the multivariate analysis (HR 4.3, P = 0.027)
  • Median survival was 12 months (95% CI 5.3 to 19.3) for patients with tumour at resected previous incisions (n = 29), and 35 months (95% CI 16.4 to 53.6) for those without (n = 13); univariate P less than 0.001
  • Stage III patients with tumour spread at previous incisions had survival comparable to stage IV patients in the full cohort (median 12 vs 8 months, P = 0.39)
  • Incomplete (R2) resections, n = 16, had a median survival of 13 months vs 35 months for macroscopic complete resection, n = 26, in univariate analysis. This was not significant in the multivariate analysis (HR 0.25, P = 0.058)
  • Males (n = 32) had a median survival of 18 months vs 68 months for females (n = 10) in univariate analysis (Table 1, P = 0.039). This was not significant in the multivariate analysis (P = 0.154)
  • Histology, lymph node metastases, T classification features, type of additional resections, laterality and age had no significant impact on survival
  • Tumour spread at previous incisions was associated with more incomplete resections (P = 0.047)
  • Progression-free survival was 11 months
  • Sites of failure among the 42 stage III patients: loco-regional only 20/42 (47.6%), distant only 6/42 (14.3%), both 6/42 (14.3%)
• The authors' conclusion: The authors concluded that lung-sparing radical pleurectomy for IMIG stage III malignant pleural mesothelioma is feasible and offers promising long-term survival. They found that tumour spread at resected previous incisions was a negative prognosticator, and proposed that such spread at incisions or chest tube sites should be considered T4 or stage IV. They also said the high rate of loco-regional failure warrants further investigation.
• Limitations the authors state:
  • Relatively small number of patients from a single institution limits interpretation and strong conclusions
  • No control groups
  • The favourable survival could be due to patient selection
  • Lymph node sampling may have been incomplete, which may have affected the analyses
  • The hormonal status of the women was not available

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: IMIG, Pleural Mesothelioma, Median Survival, Progression-Free Survival, Thoracoscopy, Histology, Hazard Ratio, Multivariate Analysis.

Related studies

• Lung-sparing total pleurectomy: the surgical option of choice in malignant pleural mesothelioma? — D.A. Waller (2013)
• Long-term survival after lung-sparing total pleurectomy for locally advanced (International Mesothelioma Interest Group Stage T3-T4) non-sarcomatoid malignant pleural mesothelioma — A. Nakas, E. von Meyenfeldt, et al. (2012)
• Prospective study on functional results after lung-sparing radical pleurectomy in the management of malignant pleural mesothelioma — S. Bölükbas, M. Eberlein, et al. (2012)
• Optimal gross tumor volume definition in lung-sparing intensity modulated radiotherapy for pleural mesothelioma: an in silico study — A. Botticella, G. Defraene, et al. (2016)
• Non-incisional pleurectomy-decortication for malignant pleural mesothelioma — F. Tanaka, N. Imanishi, et al. (2018)
• Survival after trimodality therapy for malignant pleural mesothelioma: Radical Pleurectomy, chemotherapy with Cisplatin/Pemetrexed and radiotherapy — S. Bölükbas, C. Manegold, et al. (2011)

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