Is pleurectomy and decortication superior to palliative care in the treatment of malignant pleural mesothelioma?

Our plain-English summary of Is pleurectomy and decortication superior to palliative care in the treatment of malignant pleural mesothelioma?, by I. Zahid, S. Sharif, T. Routledge, et al (Interactive Cardiovascular and Thoracic Surgery, 2011).

The study

• Authors: I. Zahid, S. Sharif, T. Routledge, M. Scarci
• Journal: Interactive Cardiovascular and Thoracic Surgery
• Published: 2011;12(5):812-7
• Type of article: Review
• Cited by: 16 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 pleurectomy/decortication (P/D) is superior to palliative care in the treatment of patients with malignant pleural mesothelioma (MPM). Overall 80 papers were found using the reported search, of which 11 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 P/D may lead to superior survival rates but at the expense of higher morbidity rates to palliative treatment. Six studies reported patient outcomes after use of radical P/D to treat patients with MPM. Radical P/D leads to a higher median survival than supportive care (14.5 vs. 4.5 months) and non-radical decortication (15.3 vs. 7.1 months, P < 0.000). However, radical P/D had a complication rate of 30%, hospital stay of 12 days with an operative mortality rate of 9.1%. One-year survival rate was 65% but this fell to 0-24% at three years. Three studies highlighted the use of palliative chemotherapy to manage patients with MPM. Median survival (14 vs. 10 months) was higher in patients who received chemotherapy early compared to those on a delayed protocol. Early chemotherapy had a longer time to disease progression (25 vs. 11 weeks, P = 0.1) and greater one-year survival (66% vs. 36%) than the delayed group. Active symptom control (ASC) alone had lower symptom control rates than the combination of ASC plus MVP (mitomycin+vinblastine+cisplatin) (7% vs. 11%, P = 0.0017) and ASC plus vinorelbine (4% vs. 7%, P = 0.047). Three studies reported results of palliative surgery in patients with known MPM. Median survival period was 213 days with a 30-day mortality rate of 7.8%. Survival rates reduced from 70.6% at three months to 25.5% at one-year post-surgery. Prolonged air-leak and postoperative empyema complicated 9.8% and 4% of patients, respectively. P/D is a morbid operation that is associated with significant perioperative mortality and complication rates. Although a number of retrospective studies have shown a small benefit in survival with P/D, the heavily documented similarity in patient outcomes between P/D and extrapleural pneumonectomy along with the results of the Mesothelioma and Radical Surgery trial, should induce the surgical community to consider the use of P/D only in patients with malignant mesothelioma enrolled in prospective trials.

In plain English

This article was a "best evidence topic", a structured literature review. It asked whether pleurectomy/decortication (P/D), an operation to remove the pleura, is better than palliative care for malignant pleural mesothelioma. A Medline search covering 1950 to August 2010 found 80 papers, and the authors chose 11 as the best evidence. In an included systematic review by Maziak et al., median survival was 14.5 months after P/D and 4.5 months with supportive care. That review reported an operative mortality rate of 9.1% and a complication rate of 30% for P/D. Nakas et al. reported longer median survival after radical P/D than after non-radical decortication (15.3 vs. 7.1 months), but more complications (55% vs. 28%). In a randomised trial by O'Brien et al., early chemotherapy gave longer median survival than delayed chemotherapy (14 vs. 10 months). The authors also cited early results of the MARS trial, which studied a different operation, extrapleural pneumonectomy. The authors concluded that P/D is a morbid operation that should be considered only for patients enrolled in prospective trials. The article did not study 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, not new research
• Who was studied: 11 papers judged the best evidence, out of 80 found in a Medline search covering 1950 to August 2010. The included studies covered patients with malignant pleural mesothelioma.
• Exposure: No asbestos exposure was studied. The review compared treatments: pleurectomy/decortication versus palliative care (supportive care, palliative chemotherapy, palliative surgery) for malignant pleural mesothelioma.
• Main results:
  • Systematic review by Maziak et al. (32 studies): median survival was 14.5 months with P/D versus 4.5 months with supportive care. P/D had an operative mortality rate of 9.1% and a complication rate of 30%.
  • Nakas et al.: radical P/D (n=51) compared with non-radical decortication (n=51) had a median survival of 15.3 versus 7.1 months (reported as P less than 0.000).
  • Nakas et al.: radical P/D had higher morbidity rates than non-radical decortication (55% vs. 28%, P=0.023).
  • Aziz et al.: median survival was 14 months with P/D (n=47), 7 months with supportive care and 13 months with extrapleural pneumonectomy (n=64). Survival after P/D was 65% at one year and 0% at three years.
  • O'Brien et al. randomised trial: early chemotherapy (n=21) gave a longer median survival (14 vs. 10 months) and a higher one-year survival rate (66% vs. 36%) than chemotherapy delayed by 17 weeks (n=17).
  • Muers et al. randomised trial: adding chemotherapy to active symptom control improved chest pain (11% vs. 7%, P=0.0017) and sweating (9% vs. 5%, P=0.012) compared with active symptom control alone.
  • Muers et al.: median survival was 8.5 months with added chemotherapy versus 7.6 months with active symptom control alone, which the authors called a marginal advantage.
  • Martin-Ucar et al.: after palliative surgical debulking (n=51), median survival was 215 days. Survival fell from 70.6% at three months to 25.5% at one year after surgery.
  • MARS trial initial results, cited by the authors (this concerned extrapleural pneumonectomy, not P/D): 12-month survival was 52.2% with extrapleural pneumonectomy (n=24) versus 73.1% without it (n=26). The hazard ratio was 2.75 (95% CI 1.21 to 6.26, P=0.02) in favour of no extrapleural pneumonectomy.
• The authors' conclusion: The authors concluded that P/D is a morbid operation with significant perioperative mortality and complication rates. They said surgeons should consider it only for patients with malignant mesothelioma enrolled in prospective trials.
• Limitations the authors state:
  • In the included study by Nakas et al., a pathological diagnosis of mesothelioma was established in only 65% of patients. The rest were treated on the basis of highly suspicious pleural biopsies.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Palliative Care, Pleural Mesothelioma, Thoracic Surgery, Pleurectomy/Decortication (P/D), Median Overall Survival, Chemotherapy, Disease Progression, Cisplatin.

Related studies

• Extrapleural pneumonectomy or supportive care: treatment of malignant pleural mesothelioma? — S. Sharif, I. Zahid, et al. (2011)
• Pleurectomy decortication for mesothelioma: The procedure of choice when possible — R.M. Flores (2016)
• Nonselective transarterial chemoperfusion: a palliative treatment for malignant pleural mesothelioma — T.J. Vogl, S. Lindemayr, et al. (2013)
• Does positron emission tomography offer prognostic information in malignant pleural mesothelioma? — S. Sharif, I. Zahid, et al. (2011)
• Efficacy of Cell-Free and Concentrated Ascites Reinfusion Therapy for Palliative Care in a Patient with Malignant Pleural Mesothelioma: A Case Report — K. Hisakane, H. Ohmatsu, et al. (2017)
• Current Treatment of Mesothelioma: Extrapleural Pneumonectomy Versus Pleurectomy/Decortication — A.S. Wolf, R.M. Flores (2016)

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