Non-incisional pleurectomy/decortication for malignant pleural mesothelioma

Our plain-English summary of Non-incisional pleurectomy/decortication for malignant pleural mesothelioma, by F. Tanaka, M. Takenaka, N. Imanishi, et al (General Thoracic and Cardiovascular Surgery, 2021).

The study

• Authors: F. Tanaka, M. Takenaka, N. Imanishi, A. Hirai, M. Kanayama, M. Mori, H. Matsumiya, A. Taira, S. Shinohara, K. Kuroda
• Journal: General Thoracic and Cardiovascular Surgery
• Published: 2021;69(9):1320-1325
• Cited by: 5 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objective: Pleurectomy/decortication has been preferably employed as a curative-intent surgery for malignant pleural mesothelioma. However, visceral pleurectomy during pleurectomy/decortication provides technical challenges. For visceral pleurectomy, pleural incisions are commonly made to create a dissection plane between the visceral pleura and the lung parenchyma, which may cause tumor dissemination and may not allow en bloc complete resection of the entire pleura. To overcome such potential disadvantages, we have developed a novel surgical technique without any pleural incision (non-incisional pleurectomy/decortication) to achieve en bloc removal of the entire pleura.

Methods: A total of 36 consecutive patients who underwent non-incisional pleurectomy/decortication for malignant pleural mesothelioma from January 2017 through December 2020 in our institute were retrospectively reviewed to assess the feasibility.

Results: Macroscopic complete resection was achieved in 31 patients (86.1%) with non-incisional pleurectomy/decortication. In the majority of patients (n = 29), en bloc complete resection of the entire pleura was achieved (without pleural laceration in 10 and with some pleural laceration in 19 patients). The total operation time and the duration of visceral pleurectomy were significantly shorter as compared with those for conventional pleurectomy/decortication (median, 350 versus 506 min [P = 0.011], and 43 versus 97 min [P < 0.001], respectively). Among 36 patients who underwent non-incisional pleurectomy/decortication, postoperative complications developed in 13 patients (36.1%), and one patient died on the postoperative day 95 caused by aggressive tumor progression of residual tumor.

Conclusions: Non-incisional pleurectomy/decortication is a fast and feasible technique to achieve en bloc macroscopic complete resection for malignant pleural mesothelioma.

© 2021. The Japanese Association for Thoracic Surgery.

In plain English

This retrospective review from one hospital in Kitakyushu, Japan, assessed a surgical technique the authors developed for malignant pleural mesothelioma: pleurectomy/decortication done without cutting into the pleura ("non-incisional"), intended to remove the entire pleura in one piece. It covered 36 consecutive patients operated on from January 2017 through December 2020, 29 (80.6%) of whom had asbestos exposure. Ten earlier patients who had conventional surgery were reviewed for exploratory comparison. All visible tumor was removed in 31 of 36 patients (86.1%). In 29, the entire pleura came out in one piece: 10 without tears, 19 with some tearing. Median operation time was 350 minutes, versus 506 minutes for conventional surgery. Complications of grade 3 or higher occurred in 13 patients (36.1%), versus 50.0% after conventional surgery, a difference that was not statistically significant. One patient died on day 95 after surgery from tumor progression. Estimated 2-year survival was 63.2%. The authors concluded the technique was fast and feasible. They noted the small, single-institution, retrospective design and short follow-up (median 493 days), and said longer follow-up is needed to judge any survival benefit.

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: Single-institution retrospective review of a surgical technique (feasibility study), with an exploratory comparison against earlier patients who had conventional pleurectomy/decortication
• Who was studied: 36 consecutive patients with malignant pleural mesothelioma who had non-incisional pleurectomy/decortication from January 2017 through December 2020 at the University of Occupational and Environmental Health, Kitakyushu, Japan (median age 69, range 47 to 79; 33 male). For exploratory comparison, 10 consecutive patients who had conventional pleurectomy/decortication from January 2012 through December 2016 were also reviewed.
• Exposure: The study compared surgical techniques: non-incisional versus conventional pleurectomy/decortication. Asbestos exposure was recorded as present in 29 of the 36 non-incisional patients (80.6%). No fiber types, jobs or doses were reported.
• Main results:
  • Among the 36 non-incisional patients, macroscopic complete resection (removal of all visible tumor) was achieved in 31 (86.1%)
  • Among the 36 non-incisional patients, en bloc macroscopic complete resection of the entire pleura was achieved in 29 (80.6%): in 10 without any pleural laceration and in 19 with some laceration
  • In 5 of the 36 non-incisional patients (13.9%), macroscopic complete resection was not achieved because the tumor had invaded mediastinal organs such as the superior vena cava
  • Median total operation time was 350 minutes for non-incisional surgery versus 506 minutes for conventional surgery (P = 0.011)
  • Median duration of the visceral pleurectomy step was 43 minutes for non-incisional surgery versus 97 minutes for conventional surgery (P less than 0.001)
  • Postoperative complications (grade 3 or higher) occurred in 13 of the 36 non-incisional patients (36.1%)
  • The complication rate was 50.0% after conventional surgery. The difference from non-incisional surgery was not statistically significant (P = 0.717).
  • One non-incisional patient died on postoperative day 95 from aggressive progression of residual tumor. There were no deaths after conventional surgery.
  • Median postoperative hospital stay was 23 days for non-incisional surgery versus 21 days for conventional surgery (P = 0.885, not significant)
  • After non-incisional surgery, estimated overall survival was 91.4% at 1 year and 63.2% at 2 years, with an estimated median overall survival of 35.5 months
  • After a median follow-up of 493 days, 20 of the 36 non-incisional patients (55.6%) were alive without tumor recurrence. The other 16 had local recurrence.
  • After non-incisional surgery, estimated relapse-free survival was 82.2% at 1 year and 50.9% at 2 years
  • Among non-incisional patients, those with epithelioid mesothelioma had significantly better overall survival than those with non-epithelioid mesothelioma
  • In exploratory analyses, overall survival did not differ between non-incisional and conventional patients when all mesothelioma patients were considered. Among patients with epithelioid mesothelioma, overall survival was significantly more favorable after non-incisional surgery.
• The authors' conclusion: The authors concluded that non-incisional pleurectomy/decortication is a fast and feasible technique for removing the entire pleura in one piece and may offer advantages over conventional surgery. They said whether it improves prognosis should be examined after longer follow-up.
• Limitations the authors state:
  • Only 36 patients from a single institution were analyzed retrospectively; the authors said a multi-institutional prospective study is needed
  • The technique may not be applicable to all patients with resectable mesothelioma. Removal without any pleural laceration may be possible only in selected cases.
  • Pleural laceration during non-incisional surgery may still cause tumor dissemination
  • Follow-up was short (median 493 days)
  • The study was non-randomized and retrospective and gave only preliminary results on feasibility

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, Visceral Pleura, Parenchyma, Pleura.

Related studies

• Non-incisional pleurectomy-decortication for malignant pleural mesothelioma — F. Tanaka, N. Imanishi, et al. (2018)
• Extended pleurectomy decortication for thymoma with pleural dissemination — N. Imanishi, Y. Nabe, et al. (2019)
• A feasibility study of induction pemetrexed plus cisplatin followed by pleurectomy/decortication aimed at macroscopic complete resection for malignant pleural mesothelioma — M. Shimokawa, S. Hasegawa, et al. (2013)
• Extended Pleurectomy and Decortication for Malignant Pleural Mesothelioma Is an Effective and Safe Cytoreductive Surgery in the Elderly — T. Williams, H. Duraid, et al. (2015)
• Pleurectomy/decortication for palliation in malignant pleural mesothelioma: results of surgery — O. Soysal, N. Karaoğlanoğlu, et al. (1997)
• Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma — S. Hasegawa (2014)

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