Interim results of pleurectomy/decortication and intraoperative intrapleural hyperthermic cisplatin perfusion for patients with malignant pleural mesothelioma intolerable to extrapleural pneumonectomy

Our plain-English summary of Interim results of pleurectomy/decortication and intraoperative intrapleural hyperthermic cisplatin perfusion for patients with malignant pleural mesothelioma intolerable to extrapleural pneumonectomy, by H. Ishibashi, M. Kobayashi, C. Takasaki, et al (General Thoracic and Cardiovascular Surgery, 2015).

The study

• Authors: H. Ishibashi, M. Kobayashi, C. Takasaki, K. Okubo
• Journal: General Thoracic and Cardiovascular Surgery
• Published: 2015;63(7):395-400
• Cited by: 19 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objective: Surgical procedure for malignant pleural mesothelioma (MPM) remains controversial. We reviewed our protocol including pleurectomy/decortication (P/D) for patients with malignant pleural mesothelioma who were intolerable to extrapleural pneumonectomy (EPP).

Patients And Methods: From June 2010 to April 2014, 14 patients with MPM were intended to treat with multimodality therapy including surgery. Four patients who were intolerable to EPP received a protocol consisting of P/D and intraoperative intrapleural hyperthermic cisplatin perfusion, followed by systemic chemotherapy. Ten patients received trimodality treatment of EPP, systemic chemotherapy, and intensity modulated radiation therapy for hemithorax. Surgical outcomes of acute operative results and interim survivals were examined and compared between the groups.

Results: All patients obtained macroscopic complete resection and received multimodality treatment in P/D and EPP groups. Operation time was longer in P/D group; however, there were no differences in ICU stays or hospitalizations. Four patients in P/D group and seven patients in EPP group experienced postoperative complications; however, there was no operative morality. EPP group suffered from cardiac complications and P/D group had prolonged airleak. Full walk recovery was obtained earlier in P/D group. One patient in P/D group had a local recurrence 11 months after surgery, while the other three patients survived 23-41 months with no evidence of diseases.

Conclusions: P/D and intraoperative intrapleural cisplatin perfusion achieved a favorable macroscopic resection in patients with MPM who were intolerable to EPP. Postoperative complications were manageable and survival could be promising. Further study warrants with a larger number of patients.

In plain English

This was a review, at one Tokyo university hospital, of 14 patients with malignant pleural mesothelioma treated with surgery plus other therapies between June 2010 and April 2014. Four patients unable to tolerate extrapleural pneumonectomy (EPP) had pleurectomy/decortication (P/D) with heated cisplatin circulated through the chest cavity during surgery, followed by chemotherapy. Ten patients had EPP, chemotherapy and radiation to the chest. In all 14, all visible tumor was removed. P/D operations took longer and chest tubes stayed in longer (13.0 versus 2.9 days), but P/D patients walked sooner. Complications occurred in all 4 P/D patients and 7 of 10 EPP patients. There were no operative deaths. Heart failure occurred in 4 EPP patients and no P/D patients, a difference that was not statistically significant. One P/D patient had a recurrence at 11 months. The other three were alive without evidence of disease 23 to 41 months after surgery. Because disease stages differed between the groups, the authors did not compare survival. The authors concluded that P/D could provide complete visible removal and multimodality treatment for these patients and that survival could be promising. They called for larger studies.

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 review of two surgical treatment protocols used at the same time at one institution (4 patients versus 10 patients), comparing operative outcomes and reporting interim disease-free survival
• Who was studied: 14 patients with malignant pleural mesothelioma (MPM) at Tokyo Medical and Dental University, June 2010 to April 2014. P/D group: 4 patients (2 men, 2 women) considered unable to tolerate EPP because of poor performance status (2), past myocardial infarction (1) or age over 75 (1). EPP group: 10 patients (9 men, 1 woman).
• Exposure: The article does not report asbestos exposure. It compared treatments. P/D group: pleurectomy/decortication, then intraoperative intrapleural hyperthermic cisplatin perfusion (cisplatin 80 mg/m2 in 2 L saline at 42 C for 1 hour), then 4 planned cycles of cisplatin and pemetrexed. EPP group: extrapleural pneumonectomy, then cisplatin and pemetrexed, then intensity modulated radiation therapy (50.4 Gy) to the entire hemithorax.
• Main results:
  • Macroscopic complete resection (removal of all visible tumor) was achieved in all patients in both groups.
  • Operation time was longer in the P/D group: mean 745 plus or minus 30 minutes versus 537 plus or minus 30 minutes in the EPP group (p = 0.0019).
  • Patients in the P/D group walked fully in the ward earlier: mean 4.0 plus or minus 1.1 days versus 6.0 plus or minus 0.4 days in the EPP group (p = 0.0470).
  • Chest tubes were removed later in the P/D group: mean 13.0 plus or minus 2.9 days versus 2.9 plus or minus 0.6 days in the EPP group (p = 0.0002).
  • Length of hospital stay did not differ between groups (mean 30.3 days P/D versus 23.1 days EPP, p = 0.1988).
  • There was no operative mortality in either group.
  • Postoperative complications occurred in 4 of 4 patients in the P/D group and 7 of 10 patients in the EPP group.
  • Heart failure occurred in 0 of 4 P/D patients and 4 of 10 EPP patients (p = 0.2507, not statistically significant).
  • Additional daily diuretic use occurred in 0 of 4 P/D patients and 8 of 10 EPP patients (p = 0.0150).
  • Reoperation was needed for prolonged air leak and diaphragmatic hernia in the P/D group, and for chylothorax in the EPP group.
  • The decrease in percent vital capacity after surgery tended to be smaller in the P/D group: mean 27.0 plus or minus 7.2 versus 42.8 plus or minus 4.3 in the EPP group (p = 0.0823, not statistically significant).
  • Disease stage distribution differed significantly between groups. The P/D group had stage I in 3 and stage III in 1. The EPP group had stage II in 1 and stage III in 9 (p = 0.0403).
  • In the P/D group, one patient had a recurrence (intrapulmonary nodule) 11 months after surgery and died 35 months after the first surgery.
  • The other three P/D patients were alive with no evidence of disease 23 to 41 months after surgery.
  • Two-year disease-free survival was 75 % in the P/D group; median disease-free survival was not reached.
  • Two-year disease-free survival was 27 % in the EPP group, with median disease-free survival of 12.1 months. The authors did not statistically compare survival between groups.
• The authors' conclusion: The authors concluded that P/D could provide macroscopic complete resection and multimodality treatment for patients with MPM who could not tolerate EPP. They stated that all patients had some complications but recovered, that survival could be promising, and that further study with more patients is warranted.
• Limitations the authors state:
  • Few patients were enrolled and follow-up was not long enough.
  • Disease stages differed so much between groups that the authors considered a survival comparison unscientific and did not perform one.
  • The effectiveness or toxicity of each separate treatment within the combined protocol cannot be evaluated.
  • Longer follow-up with more patients is needed to prove the protocol's effectiveness.

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: Pleurectomy/Decortication (P/D), Cisplatin, Pleural Mesothelioma, Extrapleural Pneumonectomy (EPP), Multimodal Therapy, Chemotherapy, Hemithorax.

Related studies

• Local and systemic exposure of cisplatin during hyperthermic intrathoracic chemotherapy perfusion after pleurectomy and decortication for treatment of pleural malignancies — M. Ried, T. Potzger, et al. (2013)
• Hyperthermic intraoperative pleural cisplatin chemotherapy extends interval to recurrence and survival among low-risk patients with malignant pleural mesothelioma undergoing surgical macroscopic complete resection — D.J. Sugarbaker, R.R. Gill, et al. (2013)
• Acute kidney injury after cytoreductive surgery and hyperthermic intraoperative cisplatin chemotherapy for malignant pleural mesothelioma — T. Hod, K.J. Freedberg, et al. (2021)
• Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma — S. Hasegawa (2014)
• Pharmacokinetic evaluation of intrapleural perfusion with hyperthermic chemotherapy using cisplatin in patients with malignant pleural effusion — H. Sakaguchi, H. Ishida, et al. (2017)
• Pleurectomy/decortication and hyperthermic intrapleural chemotherapy for malignant pleural mesothelioma: initial experience — M. Migliore, D. Calvo, et al. (2015)

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