Multifactorial Evaluation following Cytoreductive Surgery for Malignant Pleural Mesothelioma in Patients with High Symptom-Burden

Our plain-English summary of Multifactorial Evaluation following Cytoreductive Surgery for Malignant Pleural Mesothelioma in Patients with High Symptom-Burden, by R. Tajè, R. Fiorito, A. Patirelis, et al (Journal of Clinical Medicine, 2022).

The study

• Authors: R. Tajè, R. Fiorito, A. Patirelis, V. Marziali, V. Ambrogi
• Journal: Journal of Clinical Medicine
• Published: 2022;11(21)
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Mesothelioma has a scant prognosis and a great impact on symptoms and the quality of life. Pleurectomy/decortication and extrapleural pneumonectomy are the two cytoreductive surgical strategies, with different invasiveness, but achieving similar oncological results. Hereafter, the two surgical procedures effects on symptoms and the quality of life are compared in a high symptom-burden population. Between 2003 and 2017, 55 consecutive patients underwent pleurectomy/decortication (n = 26) or extrapleural pneumonectomy (n = 29), both followed by adjuvant chemo-radiotherapy. Cardio-pulmonary function, symptoms and the quality of life (Short-Form-36 and St.George's questionnaires) were evaluated pre- and 3-, 6-, 12- and 24-months postoperatively. Extrapleural pneumonectomy demonstrated lower pain at 12 months but a higher decrement of forced vital capacity at 24 months than pleurectomy/decortication. Both procedures revealed a 3-months improvement of many symptoms and the quality of life determinants. Improvement in physical, social and pain-related measured parameters lasted for a longer time-spawn in the extrapleural pneumonectomy group. No differences were found in chemotherapy compliance and survival between groups. Age-at-presentation (p = 0.02) and non-epitheliod histology (p = 0.10) were the only significant prognosticators. Surgery, despite poor survival results, improved symptoms and the quality of life in patients with mesothelioma with high symptom-burden at diagnosis. Therefore, extrapleural pneumonectomy demonstrated the most durable effects.

In plain English

This retrospective study compared two operations for malignant pleural mesothelioma in 55 consecutive patients with a high symptom burden, operated on from 2003 to 2017. Of these, 26 had pleurectomy/decortication and 29 extrapleural pneumonectomy, with chemotherapy and radiotherapy. The article does not report asbestos exposure. Symptoms, lung function and quality of life were measured before surgery and at 3, 6, 12 and 24 months. At 24 months only 5 and 9 patients, respectively, were assessed. Pain at 12 months was lower after extrapleural pneumonectomy (p = 0.005), and forced vital capacity at 24 months was higher after pleurectomy/decortication (p = 0.003). Quality-of-life scores did not differ significantly between the groups. Both groups improved on many measures at 3 months. After extrapleural pneumonectomy, pain and breathlessness stayed improved longer, while forced vital capacity fell steadily. Median survival was 14 months. Survival did not differ significantly by surgery type (p = 0.54); age over 65 and nonepithelial histology were associated with poorer survival. The authors concluded that surgery was not very effective in prolonging survival but can have some effects on symptoms and quality of life. They noted a small sample and possible selection bias.

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 comparison of two cytoreductive operations (pleurectomy/decortication versus extrapleural pneumonectomy), using data from a prospectively organized database
• Who was studied: 55 consecutive patients with malignant pleural mesothelioma and a high preoperative symptom burden, 49 men and 6 women, aged 61.8 plus or minus 10.0 years, operated on from 2003 to 2017. Of these, 26 (47.3%) had pleurectomy/decortication and 29 (52.7%) had extrapleural pneumonectomy. The authors are from Tor Vergata University, Rome. The article does not explicitly name the treating hospital.
• Exposure: Not an asbestos-exposure study: the article does not report asbestos or fiber exposure. What was compared were the two operations, with chemotherapy and radiotherapy. Chemotherapy was cisplatin with gemcitabine, later replaced by pemetrexed. Adjuvant chemotherapy was given in 40/55 patients, neoadjuvant in 12/55, and both in 3/55.
• Main results:
  • Comparing the two groups, pain at 12 months was significantly lower after extrapleural pneumonectomy: visual analogue scale 3.8 versus 5.8 after pleurectomy/decortication, p = 0.005.
  • At 24 months, forced vital capacity was higher after pleurectomy/decortication (60.8, 5 patients) than after extrapleural pneumonectomy (47.8, 9 patients), p = 0.003.
  • Within the pleurectomy/decortication group, pain improved significantly at 3 and 6 months compared with before surgery and worsened after that. Dyspnea and forced vital capacity improved up to 6 months and then returned to preoperative values. The 6-minute walk was improved up to 12 months.
  • Within the extrapleural pneumonectomy group, the authors reported that pain, the 6-minute walk and dyspnea stayed improved throughout follow-up. Their Table 5 shows the 6-minute walk at 12 months was not statistically significant (p = 0.13). Forced vital capacity fell continuously, from 70.8 before surgery to 47.8 at 24 months.
  • No significant difference between the two groups was found at any follow-up time in the SF-36 or St. George's Respiratory Questionnaire domains.
  • In both groups, SF-36 bodily pain improved most at 3 months. It went from 13.7 to 37.5 after pleurectomy/decortication and from 14.1 to 37.9 after extrapleural pneumonectomy. Scores later declined toward or past baseline.
  • At 24 months, the SF-36 mental component summary had dropped in both groups compared with before surgery: from 48.6 to 28.7 (p = 0.026) after pleurectomy/decortication and from 48.7 to 27.3 (p = 0.005) after extrapleural pneumonectomy.
  • Major 30-day complications occurred in 30.9% (17/55) of patients, with no deaths within 30 days. Table 1 reports complications in 5 (19.2%) pleurectomy/decortication patients and 12 (41.4%) extrapleural pneumonectomy patients (p = 0.076), and 3 (5.4%) deaths within 90 days.
  • 38 patients (69.1%) received the planned chemotherapy cycles and 17 did not complete them. Chemotherapy administration did not differ between the groups (p = 0.44).
  • Overall median survival was 14 months, and 37 patients (67.3%) died within 2 years of the operation. Survival did not differ significantly by type of surgery (p = 0.54), and preoperative symptoms or quality-of-life domains were not significantly related to survival. In univariate analysis, nonepithelial histology (p = 0.007) and age over 65 (p = 0.001) were significantly associated with prognosis.
  • In multivariate (Cox) analysis, two factors were the only significant predictors of shorter survival. Age over 65 had a hazard ratio of 2.91 (95% confidence interval 1.50 to 5.66, p = 0.002). Nonepithelial histology had a hazard ratio of 2.41 (95% confidence interval 1.24 to 4.71, p = 0.010).
• The authors' conclusion: The authors concluded that cytoreductive surgery was not very effective in prolonging overall survival, but can have some effects on symptom control and quality of life in patients with a high symptom burden. In their experience, pain control was more effective and longer-lasting after extrapleural pneumonectomy.
• Limitations the authors state:
  • Relatively small sample size enrolled over a long period.
  • Undetected and unmeasured bias may have affected which patients got which operation. Earlier patients were more likely to have extrapleural pneumonectomy because practice shifted over time.
  • General quality-of-life questionnaires were used rather than one specific to cancer.
  • Chemotherapy was mostly based on classic agents.
  • The impact of recurrence on quality of life could not be evaluated, and data on dropout from chemotherapy or radiotherapy could not be retrieved.
  • The disease-free interval was not evaluated because early imaging was not sensitive enough to detect early recurrence.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, Pleural Mesothelioma, Mesothelioma, Prognosis, Quality of Life, Pleurectomy/Decortication (P/D), Extrapleural Pneumonectomy (EPP), Chemotherapy.

Related studies

• Thoracic complications in patients undergoing intraperitoneal heated chemotherapy with mitomycin following cytoreductive surgery — M.Y. Chen, C. Chiles, et al. (1997)
• Abdominal Wall Morbidity Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy — F. Struller, I. Koenigsrainer, et al. (2017)
• Spontaneous diaphragmatic rupture following neoadjuvant chemotherapy and cytoreductive surgery in malignant pleural mesothelioma: A case report and review of the literature — M. Cattaneo, P. Mendogni, et al. (2020)
• Commentary: Cisplatin-induced nephrotoxicity following cytoreductive surgery and heated intraoperative chemotherapy for malignant pleural mesothelioma — S.S. Groth, R.T. Ripley (2021)
• The Safety of Iterative Cytoreductive Surgery and HIPEC for Peritoneal Carcinomatosis: A High Volume Center Prospectively Maintained Database Analysis — E. Bekhor, J. Carr, et al. (2020)
• Efficacy and Insights from an Extensive Series of Cytoreductive Surgery for Peritoneal Neoplasms: A High-Volume Single-Center Experience — M. Aulicino, F. Santullo, et al. (2024)

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