Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma

Our plain-English summary of Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma, by E. Taioli, A.S. Wolf, R.M. Flores (The Annals of Thoracic Surgery, 2015).

The study

• Authors: E. Taioli, A.S. Wolf, R.M. Flores
• Journal: The Annals of Thoracic Surgery
• Published: 2015;99(2):472-80
• Type of article: Meta-analysis
• Cited by: 149 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: This comprehensive meta-analysis was conducted to answer the question as to which procedure, pleurectomy decortication (P/D) or extrapleural pneumonectomy (EPP) is more beneficial to malignant pleural mesothelioma patients' outcome.

Methods: Original research studies that evaluated long-term outcomes of P/D versus EPP were identified, from January 1990 to January 2014. The combined percent perioperative and 2-year mortality, and median survival were calculated according to both a fixed and a random effect model. The Q statistics and I(2) statistic were used to test for heterogeneity between the studies.

Results: There were 24 distinct data sets, for a total of 1,512 patients treated with P/D, and 1,391 treated with EPP. There was a significantly higher proportion of short-term deaths in the EPP group versus the P/D group (percent mortality meta estimate; 4.5% vs 1.7%; p < 0.05). There was no statistically significant difference in 2-year mortality between the 2 groups, but there was significant heterogeneity.

Conclusions: The reanalysis of the large number of studies comparing P/D to EPP suggests that P/D is associated with a 2 ½-fold lower short-term mortality (perioperatively and within 30 days) than EPP. Pleurectomy decortication should therefore be preferred when technically feasible.

Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

In plain English

This was a meta-analysis, a study that pools results from earlier published studies. The authors searched PubMed and Embase for studies from January 1990 to January 2014 that compared two operations for malignant pleural mesothelioma: pleurectomy decortication (P/D) and extrapleural pneumonectomy (EPP). They included 27 articles forming 24 distinct data sets, covering 1,512 patients treated with P/D and 1,391 treated with EPP. In 19 studies with short-term data, the pooled proportion of patients who died around the time of surgery or within 30 days was 4.5% after EPP and 1.7% after P/D (p less than 0.05). In the 7 studies reporting 2-year outcomes, there was no statistically significant difference between the two groups, and the results of those studies varied significantly from one another. Of 17 studies reporting median survival, 53% showed longer survival after EPP and 47% after P/D. Patients who had EPP had more complications after surgery. The authors concluded that P/D was associated with a two-and-a-half-fold lower short-term mortality and should be preferred when possible. They noted that the choice of operation may have depended on patient factors that also affect survival, and that they could not adjust for this. The study looked at surgical treatment, not at 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: Meta-analysis of published observational studies comparing two surgical procedures, identified through searches of PubMed and Embase (January 1990 to January 2014)
• Who was studied: Patients with malignant pleural mesothelioma in 24 distinct data sets drawn from 27 published articles: 1,512 treated with pleurectomy decortication and 1,391 treated with extrapleural pneumonectomy. The studies came from Germany, the USA, the UK, South Africa, Japan, Italy, Australia, Austria and Turkey.
• Exposure: Not asbestos exposure. The comparison was between two operations for pleural mesothelioma: pleurectomy decortication (P/D) and extrapleural pneumonectomy (EPP). Asbestos is mentioned only in the introduction, as the main cause of the disease.
• Main results:
  • Short-term mortality (perioperative and within 30 days) was pooled from 19 studies that had this information.
  • Pooled short-term mortality was 4.5% in the EPP group and 1.7% in the P/D group, a statistically significant difference (p less than 0.05).
  • No statistically significant heterogeneity was found among the studies used for short-term mortality.
  • The authors described the short-term finding as a 2 1/2-fold lower short-term mortality with P/D.
  • Of 17 studies reporting median survival, 53% indicated longer survival after EPP and 47% after P/D.
  • Seven studies reported 2-year outcomes, covering 622 EPP patients and 544 P/D patients.
  • There was no statistically significant difference in 2-year mortality between the two groups. The figures given were 23.8% vs 25%, and the text does not say which figure belongs to which group.
  • The studies contributing to the 2-year estimate showed statistically significant heterogeneity.
  • Short-term complications were reported in 15 of the 24 data sets (62.5%). Patients undergoing EPP had more postoperative complications than those undergoing P/D. Frequent complications were local infections, systemic infections and cardiac arrhythmia.
• The authors' conclusion: The authors concluded that P/D is associated with a 2 1/2-fold lower short-term mortality (perioperatively and within 30 days) than EPP, and that P/D should therefore be preferred when possible.
• Limitations the authors state:
  • The choice of operation in each study may have been dictated by clinical factors such as stage, histology, age or other illnesses, which may also have affected survival. This possible selection bias could not be adjusted for.
  • The studies did not report 90-day mortality.
  • Only 7 studies reported 2-year mortality, and even fewer followed patients for 5 years.
  • The 2-year summary estimate was very heterogeneous. Factors such as surgical approach, surgeon ability, centre specialization or how data were defined may have played a role.
  • Data on other treatments given alongside surgery (such as chemotherapy, photodynamic therapy and intrapleural treatments) were available only as percentages, not for individual patients, so they could not be analyzed.
  • The original articles did not report the most common causes of intraoperative death for each procedure, so these could not be compared.

Topics

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

Medical terms in this study, explained in our Lexicon: Meta-Analysis, Extrapleural Pneumonectomy (EPP), Mesothelioma, Pleural Mesothelioma, Median Survival.

Related studies

• Extrapleural Pneumonectomy Versus Pleurectomy/Decortication for Malignant Pleural Mesothelioma — N. Zhou, D.C. Rice, et al. (2022)
• Current Treatment of Mesothelioma: Extrapleural Pneumonectomy Versus Pleurectomy/Decortication — A.S. Wolf, R.M. Flores (2016)
• Extrapleural Pneumonectomy and Pleurectomy Decortication: Can We Really Compare Their Survival? — P. Bertoglio, S. Korasidis (2015)
• Short-term outcomes of pleurectomy decortication and extrapleural pneumonectomy in mesothelioma — M. van Gerwen, A. Wolf, et al. (2018)
• Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma — S. Hasegawa (2014)
• Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma — L. Lang-Lazdunski, A. Bille, et al. (2012)

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