Lymphangitic carcinomatosis: A common radiographic manifestation of local failure following extended pleurectomy/decortication in patients with malignant pleural mesothelioma

Our plain-English summary of Lymphangitic carcinomatosis: A common radiographic manifestation of local failure following extended pleurectomy/decortication in patients with malignant pleural mesothelioma, by I. Berger, K.A. Cengel, C.B. Simone, et al (Lung Cancer, 2019).

The study

• Authors: I. Berger, K.A. Cengel, C.B. Simone, E.W. Alley, L. Roshkovan, A.R. Haas, A.M. Patel, U. Khalid, M.J. Culligan, S. McNulty, S. Singhal, J.S. Friedberg, S.I. Katz
• Journal: Lung Cancer
• Published: 2019;132:94-98
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: The lymphangitic carcinomatosis (LC) pattern of metastatic malignancy is associated with a poor prognosis but is currently not well defined in malignant pleural mesothelioma (MPM). Here, we report the incidence and prognostic significance of the radiographic development of LC in MPM following extended pleurectomy/decortication (EPD).

Methods: Consecutive patients with biopsy-proven MPM undergoing EPD with intraoperative photodynamic therapy (PDT) at our institution from 2008 to 2014 were included in this retrospective study. Patients without available post-surgical clinical or imaging data for direct review were excluded. CT images were reviewed by an experienced, board-certified thoracic radiologist and confirmed by consensus review. Overall survival (OS) and progression-free survival (PFS) were calculated by Kaplan Meier methodology. Hazard ratios were compared with a cox proportional hazard model.

Results: 44 patients underwent EPD with PDT during the study period and had available clinical and imaging data. During the follow-up period (median 34 months), 17 patients (39%) developed LC at a median of 10 months after surgery (IQR 5-21 months). 16 of the 17 patients who developed LC (94%) died during the follow-up period, compared to 17 of the 27 who did not develop LC (63%). OS for the LC versus non-LC group was 53% versus 93% at 1 year and 18% versus 67% at 3 years. LC was significantly associated with a lower OS (HR 4.07; 95% confidence interval 1.44-11.48; p = 0.008). PFS for the LC group versus non-LC group was 8 months (IQR 5-9 months) compared to 17 months (IQR 11-24 months) (p < 0.001).

Conclusion: LC is a common form of failure in MPM following EPD and is associated with a poor prognosis. Thus, further studies are warranted to determine if any evidence of preoperative LC should be an absolute contraindication to EPD and may warrant an EPP or no surgery at all.

Copyright © 2019. Published by Elsevier B.V.

In plain English

This retrospective single-institution study looked at adults with biopsy-proven malignant pleural mesothelioma who had a lung-sparing operation, extended pleurectomy/decortication (EPD), with photodynamic therapy during surgery, between 2008 and 2014. Of 92 such patients, 44 had usable follow-up data. A thoracic radiologist and a team checked follow-up CT scans for lymphangitic carcinomatosis (LC), tumor spreading along the lung's lymph channels. The article did not study asbestos exposure. Over a median 34 months of follow-up, 17 patients (39%) developed LC, a median 10 months after surgery. Sixteen of the 17 patients with LC died during follow-up, compared with 17 of the 27 without LC. Three-year survival was 18% with LC and 67% without LC (95% confidence intervals 4% to 38% and 46% to 81%, respectively). On multivariable analysis, LC was significantly associated with shorter overall survival (hazard ratio 4.07; 95% CI 1.44 to 11.48). The authors concluded that LC is a common form of failure after EPD and is associated with a poor prognosis. They noted that LC was diagnosed from CT rather than tissue and that data were not collected prospectively.

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 of patient records and CT scans
• Who was studied: Adults with biopsy-proven malignant pleural mesothelioma who underwent extended pleurectomy/decortication with intraoperative photodynamic therapy at the authors' institution (University of Pennsylvania) between 2008 and 2014. Of 92 patients treated, 44 had clinical and imaging data available for review.
• Exposure: Asbestos exposure was not studied. The factor examined was whether the CT pattern of lymphangitic carcinomatosis appeared after EPD, and how this related to survival.
• Main results:
  • 17 patients (39%) developed LC, at a median of 10 months after surgery (IQR 5 to 21 months)
  • 16 of the 17 patients (94%) who developed LC died during follow-up, compared with 17 of the 27 patients (63%) without LC
  • Median overall survival was 21 months in the LC group and 51 months in the non-LC group
  • Overall survival in the LC group versus the non-LC group was 53% versus 93% at 1 year, and 18% versus 67% at 3 years
  • 3-year survival in the non-LC group was 67% (95% CI 46% to 81%)
  • 3-year survival in the LC group was 18% (95% CI 4% to 38%)
  • On multivariable analysis, developing LC was significantly associated with overall survival (HR 4.07; 95% CI 1.44 to 11.48; p = 0.008)
  • Median progression-free survival was 8 months (IQR 5 to 9) in the LC group and 17 months (IQR 11 to 24) in the non-LC group
  • Patients who developed LC were more likely to be lymph-node positive (16/17 or 94% vs. 16/27, printed as 61%, p = 0.011)
• The authors' conclusion: The authors concluded that LC is a common form of failure in malignant pleural mesothelioma after EPD and is associated with a poor prognosis. They called for further studies on whether any evidence of LC before surgery should rule out EPD.
• Limitations the authors state:
  • The data were not collected prospectively, so clinical variables, including surgical and photodynamic therapy factors, could not be controlled for
  • The results may not apply to patients who do not have EPD with intraoperative photodynamic therapy
  • Surgical pathology was not collected prospectively for direct review
  • LC was diagnosed from CT appearance, not confirmed by tissue examination, because no biopsy or autopsy data were available
  • Too few patients with LC had PET/CT scans after surgery to evaluate that type of imaging

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), Pleural Mesothelioma, Prognosis, Biopsy, Overall Survival, Progression-Free Survival, Hazard Ratio, confidence interval.

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