Mesothelioma--VATS biopsy and lung mobilization improves diagnosis and palliation

Our plain-English summary of Mesothelioma--VATS biopsy and lung mobilization improves diagnosis and palliation, by M.W. Grossebner, A.A. Arifi, M. Goddard, et al (European Journal of Cardio-thoracic Surgery, 1999).

The study

• Authors: M.W. Grossebner, A.A. Arifi, M. Goddard, A.J. Ritchie
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 1999;16(6):619-23
• Cited by: 27 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objectives: Mesothelioma is an increasingly frequent malignancy in which diagnosis is often delayed and disease diagnosed at an advanced stage. Earlier diagnosis and therapeutic intervention that can control recurrent pleural effusion may improve outlook and survival.

Methods: A prospective series of 25 patients in whom mesothelioma was suspected was referred for histological diagnosis by video assisted-thoracoscopy (VAT) after failure of other methods. At the same operative procedure drainage of pleural effusion, cytoreductive pleurectomy and lung mobilization was performed where possible. Complete follow-up was obtained.

Results: All patients had a histological diagnosis (100%) from the material sent for biopsy. In 23 patients this was mesothelioma, in two patients chronic empyema. All patients undergoing drainage of effusion, cytoreductive pleurectomy and lung mobilization subsequently were diagnosed of having mesothelioma stages III to IV. Fifteen out of 21 who underwent lung mobilization had closure of the pleural space. Post operative air leak in this group was a mean of 5 days (2-12 days). Recurrent effusion occurred in only one patient. Eleven patients remain alive at 1-2 years post operation with no hospital admissions for recurrent pleural effusion. In the six out of 21 who did not have closure of the pleural space, one remained alive 9 months post surgery. Five died within 1-6 months of the procedure. The average number of further hospital admissions for repeat drainage of effusion was 3 (1-6).

Conclusions: VATs provides adequate tissue for histological diagnosis where other methods fail. At the same operative sitting it provides a therapeutic intervention that allows drainage of effusion cytoreductive pleurectomy and lung mobilization in a significant number of cases. Where the pleural space can be closed this results in significantly fewer hospital admissions and appears to improve quality of life and length of survival. The price is a longer hospital stay due to prolonged air leak.

In plain English

This prospective series studied 25 patients (24 male, one female) at a UK hospital. All had asbestos exposure and suspected mesothelioma unconfirmed by earlier fluid tests or needle biopsies. All had keyhole chest surgery (VATS) for biopsy; where possible the same operation drained fluid, removed pleural tumour and freed the lung. Tissue diagnosis was made in all 25, with no surgical deaths. Twenty-three had mesothelioma, all stage III or IV; two had chronic empyema. Lung freeing was attempted in 21 mesothelioma patients and closed the pleural space in 15. Of those 15, one had recurrent fluid and died at 9 months; 11 were alive up to 2 years 5 months without readmission for fluid. Of the other six, five died within 1 to 6 months, and they averaged 3 further drainage admissions per patient (range 1 to 6). Reported air leak after surgery was 5 days (range 2 to 21) with closure and 3 days (range 2 to 7) without. The authors concluded that closing the pleural space was associated with longer survival and better quality of life but needs further study.

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: Prospective case series of patients treated with video-assisted thoracoscopic surgery (no randomized comparison group)
• Who was studied: 25 patients (24 male, one female; mean age 64, range 34 to 75) with suspected but unproven mesothelioma, referred after other diagnostic methods failed. The authors' department is at Papworth Hospital, Cambridge, UK. Study dates are not stated.
• Exposure: All patients had a history of asbestos exposure; fiber types, jobs and doses are not given. The study examined a surgical procedure: VATS biopsy with drainage of pleural effusion, cytoreductive pleurectomy and lung mobilization.
• Main results:
  • A histological diagnosis was made in all 25 patients, with no deaths from the procedure.
  • 23 patients had mesothelioma (12 epithelial type, nine mixed morphology, two sarcomatous) and two had chronic empyema.
  • All mesothelioma patients were assigned to Butchart stage III or IV.
  • In two mesothelioma patients only biopsy was possible; they died 2 and 4 months after diagnosis.
  • Of the 21 remaining patients, 15 had extensive cytoreductive pleurectomy with lung mobilization that closed the pleural space. The reported post-operative air leak duration in this group was 5 days (range 2 to 21 days).
  • In the 15-patient closed-space group, recurrent pleural effusion occurred in one patient, who died 9 months after the procedure. A further 11 remained alive up to 2 years 5 months with no hospital admissions for recurrent effusion.
  • The six patients whose lung was incarcerated and whose pleural space could not be closed had partial pleurectomy. The reported air leak duration in this group was 3 days (range 2 to 7 days). One patient remained alive at 11 months and five died within 1 to 6 months. This group had an average of 3 further hospital admissions per patient (range 1 to 6) for repeat drainage of effusion.
  • Incarcerated lungs that could not be mobilized were associated with parietal pleural thickness greater than 1 cm extending across the visceral pleura.
• The authors' conclusion: The authors concluded that VATS can provide enough tissue for diagnosis where other methods failed, and that at the same operation it allows treatment to palliate pleural effusion. They also concluded that cytoreductive pleurectomy and lung mobilization that closes the pleural space is associated with longer survival and better quality of life, but needs further study to clarify its direct benefits.
• Limitations the authors state:
  • The study did not determine whether the trend to longer survival was due to reducing tumour burden directly or to preventing effusion by closing the pleural space.
  • Lymph node staging could not be routinely performed because the technique does not reach the mediastinal lymph node stations.

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, Video-Assisted Thoracoscopic Surgery (VATS), Biopsy, Pleural Effusion, Thoracoscopy, Cytoreductive Surgery, Empyema, Quality of Life.

Related studies

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• Pleurectomy/decortication for palliation in malignant pleural mesothelioma: results of surgery — O. Soysal, N. Karaoğlanoğlu, et al. (1997)
• Thoracoscopic palliative treatment of malignant pleural effusions: results in 273 patients — K. Arapis, R. Caliandro, et al. (2006)
• Prognostic factors for survival after surgical palliation of malignant pleural effusion — J.E. Pilling, M.E. Dusmet, et al. (2010)
• Utility of Site-Specific Biopsy for Diagnosis of Desmoplastic Malignant Mesothelioma — T. Sakai, K. Tane, et al. (2018)
• Outcome and prognostic factors of pleural mesothelioma after surgical diagnosis and/or pleurodesis — M. Baud, S. Strano, et al. (2013)

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