Outcome after extrapleural pneumonectomy for malignant pleural mesothelioma

Our plain-English summary of Outcome after extrapleural pneumonectomy for malignant pleural mesothelioma, by C. Aigner, M.A. Hoda, G. Lang, et al (European Journal of Cardio-thoracic Surgery, 2008).

The study

• Authors: C. Aigner, M.A. Hoda, G. Lang, S. Taghavi, G. Marta, W. Klepetko
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2008;34(1):204-7
• Cited by: 16 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Malignant pleural mesothelioma is a mainly asbestos-related neoplasm that occurs with increasing frequency and is associated with a poor prognosis. Extrapleural pneumonectomy which was initially performed as a stand-alone treatment in patients with resectable disease is now currently almost uniformly applied as part of a multi-modal approach. Its value and advantage over other therapeutic strategies remain points of discussion. We therefore analysed our experience with extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma.

Methods: We retrospectively reviewed our institutional experience with all consecutive patients undergoing extrapleural pneumonectomy for malignant pleural mesothelioma from 1994 to 2005. Patients were analysed with regard to hospital mortality and morbidity and long-term outcome.

Results: Forty-nine patients (10 female/39 male, mean age 58+12 years) underwent extrapleural pneumonectomy during the observation period. Median ICU stay was 1 day, median postoperative length of hospital stay was 13 days. After a mean follow-up of 2573 days, median survival was 376 days (mean 672+121 days, range 9-3384). One-year survival was 53%, 3-year survival 27% and 5-year survival 19%.

Conclusion: Extrapleural pneumonectomy as part of a multi-modality treatment regimen is a good treatment option for selected patients with malignant pleural mesothelioma. The long-term results of this limited series compare favourably to non-surgical treatment regimens. Larger randomised prospective multi-centre trials are warranted to establish clear guidelines.

In plain English

The authors, from a cardio-thoracic surgery department in Vienna, Austria, looked back at all 49 consecutive patients (10 female, 39 male; median age 59) who had extrapleural pneumonectomy for malignant pleural mesothelioma between 1994 and 2005. In this operation the lung, pleura, pericardium and diaphragm are removed together. The study did not examine asbestos exposure. Thirteen patients had chemotherapy before surgery and 14 had further treatment afterward. Thirty-day survival was 90%. Median survival was 376 days. One-year survival was 53%, 3-year survival 27% and 5-year survival 19%. Patients with the epithelial type survived significantly longer than those with biphasic or sarcomatous types. Patients with N2 lymph node involvement did significantly worse than N0 patients. Patients given chemotherapy before surgery had a 5-year survival rate of 52%. Survival did not differ significantly between patients who had treatment after surgery and those who had surgery alone. The authors concluded that the operation, as part of combined treatment, is a good option for selected patients with epithelial malignant pleural mesothelioma. They noted that the study was retrospective, made no direct comparison with other treatments, and used chemotherapy and radiotherapy that were not standardised.

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 review of a single institution's consecutive surgical patients (surgical outcome series)
• Who was studied: 49 consecutive patients (10 female, 39 male; median age 59, range 28 to 81) who underwent extrapleural pneumonectomy for malignant pleural mesothelioma from 1994 to 2005 at the Department of Cardio-Thoracic Surgery, Medical University of Vienna, Austria. Tumour types after surgery were epithelial in 30, biphasic in 15 and sarcomatous in 4.
• Exposure: Not an asbestos exposure study. The treatment studied was extrapleural pneumonectomy. 13 patients also had induction (pre-operative) chemotherapy and 14 had adjuvant (post-operative) therapy.
• Main results:
  • In all 49 patients, median survival was 376 days after a mean follow-up of 2573 days.
  • In all patients, 30-day survival was 90%. The five deaths were from sepsis (2), pulmonary embolism (2) and cardiac arrest (1).
  • In all patients, 1-year survival was 53%, 3-year survival 27% and 5-year survival 19%. Ten patients were still alive at the time of analysis.
  • Patients with epithelial type mesothelioma had significantly better survival than those with biphasic and sarcomatous types (p = 0.01).
  • N2 positive patients had significantly worse survival than N0 patients (p = 0.01).
  • The 13 patients who received induction chemotherapy had a 5-year survival rate of 52% (p less than 0.001).
  • The authors found no statistically significant survival difference between patients receiving adjuvant therapy and those having surgery alone.
  • Patients receiving any form of multi-modality treatment had a highly significant survival benefit compared with surgery alone (p less than 0.001).
  • A microscopically complete (R0) resection was achieved in 39 of 49 patients and not in the other 10.
  • Among patients alive at 5-year follow-up, 67% of all patients and 75% of those who had induction therapy were free of tumour recurrence.
• The authors' conclusion: The authors concluded that extrapleural pneumonectomy as part of a multi-modal treatment regimen is a good treatment option for selected patients with epithelial malignant pleural mesothelioma. They also concluded that the long-term results of this limited series compare favourably to non-surgical treatment regimens, and called for larger randomised prospective multi-centre trials.
• Limitations the authors state:
  • The study is retrospective.
  • No direct comparison to other treatments was made.
  • Treatment protocols changed over the long observation period. Chemotherapy and radiotherapy were not standardised, so the patient group was heterogeneous.

Topics

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

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

Related studies

• Extrapleural pneumonectomy after induction chemotherapy: perioperative outcome in 251 mesothelioma patients from three high-volume institutions — O. Lauk, M.A. Hoda, et al. (2014)
• Impact of induction therapy on postoperative outcome after extrapleural pneumonectomy for malignant pleural mesothelioma: does induction-accelerated hemithoracic radiation increase the surgical risk? — P. Mordant, K. McRae, et al. (2016)
• Extrapleural pneumonectomy for malignant pleural mesothelioma: outcomes of treatment and prognostic factors — T.D. Yan, M. Boyer, et al. (2009)
• Hemithoracic radiation therapy after extrapleural pneumonectomy for malignant pleural mesothelioma: Toxicity and outcomes at an Australian institution — A. Bece, M.M. Tin, et al. (2015)
• Clinical and pathological features of three-year survivors of malignant pleural mesothelioma following extrapleural pneumonectomy — D.J. Sugarbaker, A.S. Wolf, et al. (2011)
• PI3K/mTOR signaling in mesothelioma patients treated with induction chemotherapy followed by extrapleural pneumonectomy — B.K. Bitanihirwe, M. Meerang, et al. (2014)

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