Malignant pleural mesothelioma and the Society of Thoracic Surgeons Database: an analysis of surgical morbidity and mortality

Our plain-English summary of Malignant pleural mesothelioma and the Society of Thoracic Surgeons Database: an analysis of surgical morbidity and mortality, by B.M. Burt, R.B. Cameron, N.M. Mollberg, et al (The Journal of Thoracic and Cardiovascular Surgery, 2014).

The study

• Authors: B.M. Burt, R.B. Cameron, N.M. Mollberg, A.S. Kosinski, P.H. Schipper, J.B. Shrager, W.T. Vigneswaran
• Journal: The Journal of Thoracic and Cardiovascular Surgery
• Published: 2014;148(1):30-5
• Cited by: 80 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: To date, reported surgical morbidity and mortality for pleurectomy/decortication and extrapleural pneumonectomy performed for malignant pleural mesothelioma primarily represent the experience of a few specialized centers. For comparison, we examined early outcomes of pleurectomy/decortication and extrapleural pneumonectomy from a broader group of centers/surgeons participating in the Society of Thoracic Surgeons-General Thoracic Database.

Methods: All patients in the Society of Thoracic Surgeons-General Thoracic Database (version 2.081, representing 2009-2011) who underwent pleurectomy/decortication or extrapleural pneumonectomy for malignant pleural mesothelioma were identified. Patient characteristics, morbidity, mortality, center volume, and procedure were examined using univariable and multivariable analyses.

Results: A total of 225 patients underwent pleurectomy/decortication (n = 130) or extrapleural pneumonectomy (n = 95) for malignant pleural mesothelioma at 48 centers. Higher volumes of procedures (≥5/y) were performed at 3 pleurectomy/decortication and 2 extrapleural pneumonectomy centers. Patient characteristics were statistically equivalent between pleurectomy/decortication and extrapleural pneumonectomy groups, except those undergoing extrapleural pneumonectomy were younger (63.2 ± 7.8 years vs 68.3 ± 9.5 years; P < .001) and more likely to have received preoperative chemotherapy (30.1% vs 17.8%; P = .036). Major morbidity was greater after extrapleural pneumonectomy, including acute respiratory distress syndrome (8.4% vs 0.8%; P = .005), reintubation (14.7% vs 2.3%; P = .001), unexpected reoperation (9.5% vs 1.5%; P = .01), and sepsis (4.2% vs 0%; P = .03), as was mortality (10.5% vs 3.1%; P = .03). Multivariate analyses revealed that extrapleural pneumonectomy was an independent predictor of major morbidity or mortality (odds ratio, 6.51; P = .001). Compared with high-volume centers, increased acute respiratory distress syndrome was seen in low-volume centers performing extrapleural pneumonectomy (0% vs 12.5%; P = .05).

Conclusions: Extrapleural pneumonectomy is associated with greater morbidity and mortality compared with pleurectomy/decortication when performed by participating surgeons of the Society of Thoracic Surgeons-General Thoracic Database. Effects of center volume require further study.

Copyright © 2014 The American Association for Thoracic Surgery. All rights reserved.

In plain English

This study looked back at records in the Society of Thoracic Surgeons General Thoracic Database for 2009 to 2011. It compared early results of two operations for malignant pleural mesothelioma. Extrapleural pneumonectomy (EPP) removes the pleura, lung, diaphragm on that side and pericardium. Pleurectomy/decortication (PD) removes the pleura but spares the lung. The study included 225 patients at 48 centers: 130 had PD and 95 had EPP. Death within 30 days or before discharge occurred in 10 of 95 EPP patients (10.5%) and 4 of 130 PD patients (3.1%). At least one major complication occurred in 24.2% after EPP and 3.8% after PD. In a multivariable analysis, EPP was linked to higher odds of major complications or death (odds ratio 6.51, 95% confidence interval 2.07 to 20.47). Lower center volume was not an independent predictor. The authors concluded that PD is associated with less postoperative morbidity and mortality than EPP. They said the effect of center volume needs further study. They noted the retrospective design and the lack of staging and tissue-type data.

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 a multi-institutional surgical database (Society of Thoracic Surgeons General Thoracic Database, version 2.081, 2009-2011). Outcomes were death within 30 days or before discharge, and major complications.
• Who was studied: 225 patients with malignant pleural mesothelioma who had PD (130) or EPP (95) at 48 participating centers during 2009-2011. Of 286 patients with pleural procedures, 61 who had incomplete procedures were excluded.
• Exposure: The article does not report asbestos exposure. The comparison was between two operations: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (PD).
• Main results:
  • Mortality was 10.5% after EPP (10 of 95) and 3.1% after PD (4 of 130), P = .027.
  • EPP patients had significantly higher rates than PD patients of acute respiratory distress syndrome (8.4% vs 0.8%), reintubation (14.7% vs 2.3%), sepsis (4.2% vs 0%) and unexpected return to the operating room (9.5% vs 1.5%).
  • At least one major complication occurred in 24.2% of EPP patients and 3.8% of PD patients.
  • In the multivariable model, EPP was an independent predictor of major morbidity or mortality (odds ratio 6.51, 95% CI 2.07-20.47, P = .001). Cerebrovascular disease was also an independent predictor (odds ratio 16.0, 95% CI 1.02-251.30).
  • Center volume of fewer than 5 procedures per year predicted major morbidity or mortality in the univariable analysis. It was not independent in the multivariable model (odds ratio 1.38, 95% CI 0.49-3.93, P = .54).
  • Among EPP patients, mortality was 6.5% at higher-volume centers and 12.5% at lower-volume centers, a difference that was not statistically significant (P = .49).
  • Among EPP patients, the authors described a trend toward more acute respiratory distress syndrome at lower-volume centers than at higher-volume centers (12.5% vs 0.0%, P = .05).
  • EPP patients were younger than PD patients (mean 63.2 vs 68.3 years). They more often had received preoperative chemotherapy (30.1% vs 17.8%). Otherwise the groups were statistically similar.
• The authors' conclusion: The authors concluded that, together with the experience of others, their results suggest PD is associated with less postoperative morbidity and mortality than EPP. They said the effect of center volume requires further study.
• Limitations the authors state:
  • Many centers that treat mesothelioma patients are not captured by the database.
  • The retrospective design brings selection and information biases.
  • Histology and staging data were not available. These factors likely influence the choice of operation, and EPP may be a marker of more extensive disease.
  • Long-term outcomes could not be compared from this dataset.
  • PD is not a standardized operation, so completeness of resection may vary by surgeon.
  • The center-volume analyses involved limited numbers of patients.

Topics

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

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Pleurectomy/Decortication (P/D), Extrapleural Pneumonectomy (EPP), Chemotherapy, Odds Ratio, High-Volume Center.

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• British Thoracic Society Guideline for the investigation and management of malignant pleural mesothelioma — I. Woolhouse, L. Bishop, et al. (2018)
• Treatment of malignant pleural mesothelioma with chemotherapy preceding versus after surgical resection — V. Verma, C.A. Ahern, et al. (2019)
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• Clinical indications and results after chest wall resection for recurrent mesothelioma — B.M. Burt, S.O. Ali, et al. (2013)
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