Long-term survival after lung-sparing total pleurectomy for locally advanced (International Mesothelioma Interest Group Stage T3-T4) non-sarcomatoid malignant pleural mesothelioma

Our plain-English summary of Long-term survival after lung-sparing total pleurectomy for locally advanced (International Mesothelioma Interest Group Stage T3-T4) non-sarcomatoid malignant pleural mesothelioma, by A. Nakas, E. von Meyenfeldt, K. Lau, et al (European Journal of Cardio-thoracic Surgery, 2012).

The study

• Authors: A. Nakas, E. von Meyenfeldt, K. Lau, S. Muller, D. Waller
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2012;41(5):1031-6
• Cited by: 41 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objectives: There is a body of opinion that advocates extrapleural pneumonectomy (EPP) as the only radical treatment option for locally advanced (T3/T4) malignant pleural mesothelioma (MPM). We tested the hypothesis that lung-sparing total pleurectomy (LSTP) can be as effective as EPP in locally advanced MPM with reduced risk.

Methods: We analysed prospective data on 165 patients (128 with epithelioid and 37 with biphasic MPM) with pT3 (n = 108) and pT4 (n = 57) tumours. Ninety-eight (59.4%) of the patients underwent EPP and 67 (40.6%) LSTP. We compared intergroup differences in: length of stay (LOS), post-operative complications, survival, pattern of disease progression and disease-free interval (DFI).

Results: There were significantly more complications after EPP: 67 (68%) vs. 29 (43%) in LSTP, P = 0.002. Thirty-day mortality was 7% for EPP and 3% for LSTP (P = 0.31). LOS was similar (mean 19 days for EPP, 15 days for LSTP, P = 0.19). We noted only minor differences in the initial site of disease progression. In 33 (41%) of EPP patients, disease progressed locally compared with 22 (44%) after LSTP. Seventeen patients post-EPP (21%) had distal progression compared with only three (6%) post-LSTP and synchronous distal and local recurrence was similar: 15 (19%) post-EPP vs. 12% for LSTP (P = 0.11). There was no significant intergroup difference in median survival: EPP 14.7 months (SE 1.3, 95% CI 12.2-17.2) vs. LSTP 13.4 months (SE 1.9, 95% CI 9.7-17.1), P = 0.91, nor in DFI: EPP 10.7 months (SE 0.8, 95% CI 9-12) vs. LSTP 16 months (SE 1, 95% CI 9-22). In chemonaive patients (n = 124), adjuvant chemotherapy was received by significantly more patients after LSTP (32/53 LSTP vs. 26/71 EPP patients, P = 0.011). Estimated 1-5 years survival for EPP was 58, 30, 11, 9 and 6% and for LSTP 52, 28, 20, 13 and 4%.

Conclusions: In disagreement with standard opinion, we advocate LSTP as the procedure of choice in locally advanced MPM: it offers at least equally as good oncological results as EPP in this group of patients with reduced early complications. Despite a tendency for increased local recurrence in the LSTP group, overall survival is not compromised.

In plain English

This study from a thoracic surgery department in Leicester, UK, compared two operations for locally advanced (pT3 or pT4) malignant pleural mesothelioma of epithelioid or biphasic cell type. The article does not discuss asbestos exposure. Of 165 patients, 98 had extrapleural pneumonectomy (EPP) and 67 had lung-sparing total pleurectomy (LSTP). Patients were offered a choice of operation rather than being randomly assigned, and the LSTP group was older on average. Significantly fewer LSTP patients had post-operative complications (29, 43%) than EPP patients (67, 68%). Deaths within 30 days were 7 (7%) after EPP and 2 (3%) after LSTP (P = 0.3). Median survival from diagnosis was 14.7 months (95% CI 12.2 to 17.2) for EPP and 13.4 months (95% CI 9.7 to 17.1) for LSTP (P = 0.91), not significantly different. Among patients with complete follow-up, local recurrence occurred in 41% of EPP and 44% of LSTP patients. The authors concluded that, for now, neither disease-free interval nor overall survival was compromised by preserving the lung. They noted that longer LSTP follow-up might widen the local-recurrence difference.

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, non-randomized comparison of two operations, using patients drawn from the department's prospective database
• Who was studied: 165 patients with malignant pleural mesothelioma of epithelioid (128) or biphasic (37) cell type and pathological stage pT3 (108) or pT4 (57), treated at the Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK, after referral from throughout the UK. 139 were male and 26 female. Sarcomatoid cell type was excluded.
• Exposure: No asbestos exposure information is reported. The comparison was between two operations: extrapleural pneumonectomy (EPP, 98 patients) and lung-sparing total pleurectomy (LSTP, 67 patients).
• Main results:
  • Post-operative complications occurred in 29 (43%) LSTP patients and 67 (68%) EPP patients, which the authors reported as significantly fewer after LSTP.
  • 30-day mortality was 7 (7%) in the EPP group and 2 (3%) in the LSTP group (P = 0.3). 90-day mortality was 17 (17%) in the EPP group and 8 (12%) in the LSTP group (P = 0.38).
  • Survival was counted from the time the disease was confirmed by tissue examination (histological confirmation), not from the date of surgery. The disease-free interval was counted from the operation.
  • There was no significant difference in overall survival between the groups. Median survival, counted from histological confirmation of disease, was 14.7 months in the EPP group (95% CI 12.2 to 17.2).
  • Median survival, counted from histological confirmation of disease, was 13.4 months in the LSTP group (95% CI 9.7 to 17.1); P = 0.91 for the comparison with EPP.
  • Among patients with complete follow-up data on disease progression (80 EPP, 50 LSTP), local disease progression occurred in 33 (41%) EPP patients and 22 (44%) LSTP patients.
  • Distant recurrence occurred in 17 (21%) EPP patients and 3 (6%) LSTP patients. Mixed local and distant recurrence occurred in 15 (19%) EPP patients and 6 (12%) LSTP patients (P = 0.113).
  • Median disease-free interval was 10.7 months for EPP (95% CI 9 to 12) and 16 months for LSTP (95% CI 9 to 22), P = 0.45, which was not a significant difference.
  • Among patients who had not received chemotherapy before surgery, 32 of 53 (60.4%) LSTP patients and 26 of 71 (36.6%) EPP patients received chemotherapy after surgery (P = 0.011).
  • The LSTP group was significantly older than the EPP group (mean age 60.7 years vs. 55.4 years).
  • Confirmed recurrence occurred in 65 (81%) EPP patients and 31 (62%) LSTP patients (P = 0.017). The authors noted that follow-up was longer in the EPP group.
• The authors' conclusion: The authors concluded that, for now, preserving the lung with LSTP compromised neither disease-free interval nor overall survival compared with EPP. They also stated that any further rise in local recurrence after LSTP remains to be proved.
• Limitations the authors state:
  • The study was retrospective and non-randomized: patients were offered a choice of operation rather than being randomly assigned.
  • There are confounding factors, and with longer follow-up of the LSTP group the difference in local recurrence might increase.
  • Follow-up was longer in the EPP group, reflecting a change over time in the department's practice from EPP to LSTP.

Topics

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

Medical terms in this study, explained in our Lexicon: Mesothelioma, Sarcomatoid, Pleural Mesothelioma, Extrapleural Pneumonectomy (EPP), Epithelioid, Biphasic Mesothelioma, Disease Progression, Median Survival.

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