Persistent lung expansion after pleural talc poudrage in non-surgically resected malignant pleural mesothelioma

Our plain-English summary of Persistent lung expansion after pleural talc poudrage in non-surgically resected malignant pleural mesothelioma, by O. Rena, R. Boldorini, E. Papalia, et al (The Annals of Thoracic Surgery, 2015).

The study

• Authors: O. Rena, R. Boldorini, E. Papalia, R. Mezzapelle, G. Baietto, A. Roncon, C. Casadio
• Journal: The Annals of Thoracic Surgery
• Published: 2015;99(4):1177-83
• Cited by: 16 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: To investigate the prognostic effect of persistent lung expansion after pleural talcage and other variables in non-surgically resected malignant pleural mesothelioma (MPM) patients.

Methods: All consecutive patients submitted to video-assisted thoracoscopic (VAT) pleurodesis by talc poudrage for MPM between 2006 and 2011 were studied. The following parameters were prospectively recorded: age; sex; smoking history; asbestos exposure; C-reactive protein (CRP) levels; platelet (PLT) count; Eastern Cooperative Oncology Group performance status (ECOG PS); histologic subtype; clinical stage (cStage); chemotherapy; pleural fluid volume; and persistence of lung expansion at 3 months follow-up. Survival was assessed in June 2013.

Results: A total of 172 patients were considered; 146 of 172 patients demonstrated a complete lung expansion at discharge, whereas only 85 of 172 patients had persistent expanded lung on the affected side at the 3-month follow-up chest x-ray. Median survival was 11.5 months (95% confidence interval [CI], 10% to 14%) and 2-year disease-specific survival was 13% (95% CI, 7% to 24%) for the entire cohort. Multivariate analysis showed that non-epithelioid histology (hazard ratio [HR], 2.81; 95% CI, 1.82% to 5.09%), pleural fluid recurrence (HR 2.54; 95% CI, 1.73% to 4.40%), cStage greater than II (HR 2.36; 95% CI, 1.50% to 4.32%), ECOG PS greater than 1 (HR 2.19; 95% CI, 1.26% to 4.23%), CRP greater than 5 mg/L (HR 2.01; 95% CI, 1.18% to 4.12%), and PLT count greater than 400,000 (HR 1.76; 95% CI 1.14% to 3.92%) were independent predictors of poor prognosis.

Conclusions: Persistent lung expansion after pleural talc poudrage and absence of fluid recurrence is demonstrated to be a stronger factor in predicting survival rather than clinical stage and other clinical variables in not surgically resected MPM patients.

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

In plain English

This study from Novara, Italy, examined 172 patients with malignant pleural mesothelioma treated in 2006 to 2011 with a keyhole chest procedure. In it, asbestos-free talc powder was blown into the chest to stop fluid building up. Patients later having tumor-removing surgery were excluded; data recorded at the time were analyzed afterward. Ninety-nine had occupational asbestos exposure. At 3 months, 85 of 172 patients still had a fully expanded lung on x-ray. For the 158 patients with survival data, 2-year disease-specific survival was 13% (95% CI 7% to 24%). Those with a lasting expanded lung had a median survival of 19.5 months (95% CI 18.5 to 22). Independent predictors of shorter survival were fluid returning by 3 months (hazard ratio 2.54, 95% CI 1.73 to 4.40), non-epithelioid tumor type (2.81, 1.82 to 5.09), stage above II, performance status 2 or worse, C-reactive protein above 5 mg/L and platelets above 400,000/mm3. Asbestos exposure was linked to shorter survival only in single-factor analysis. The authors concluded that lasting lung expansion predicted survival more strongly than clinical stage. They noted the retrospective design and varied chemotherapy as limitations.

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-center study of consecutive patients; data were collected prospectively and analyzed retrospectively
• Who was studied: 172 patients with malignant pleural mesothelioma (MPM) treated at the Thoracic Surgery Unit of Novara, Italy, between 2006 and 2011 with video-assisted thoracoscopic pleural biopsy and talc pleurodesis. The 42 patients who had extirpative surgery (EPP or P/D) were excluded from this group.
• Exposure: The treatment studied was talc poudrage pleurodesis: 4 to 6 grams of asbestos-free talc powder blown into the pleural cavity. Occupational asbestos exposure was recorded as one patient variable.
• Main results:
  • 99 patients had a history of working (occupational) asbestos exposure. The article prints this as 59%, which does not match 99 of the 172 patients (about 58%), and the article does not explain the denominator.
  • 146 patients (84%) had complete lung expansion after chest drain removal
  • At the 3-month follow-up chest x-ray, 85 of 172 patients had a persistently expanded lung (complete response). The rest had partial (27%) or no (24%) response.
  • Complete response at 3 months occurred in 69 epithelioid tumors (55%) and 17 non-epithelioid tumors (35%)
  • Response to pleurodesis did not differ significantly by clinical stage: stage II 53%, stage above II 43%
  • Patients with complete response had significantly less pleural fluid at the time of the procedure than those with partial or no response
  • Disease-specific survival data were obtained for 158 of the 172 patients (92%); the others were lost to follow-up
  • Two-year disease-specific survival for the entire cohort was 13% (95% CI, 7% to 24%)
  • By June 30, 2013, 27 patients were alive and 131 had died, among the 158 with survival data
  • Median survival for patients with persistent lung expansion at the 3-month chest x-ray was 19.5 months (95% CI 18.5 to 22 months; the article prints the limits with percent signs)
  • Patients with complete control of pleural fluid had a 2-year disease-specific survival of about 30%
  • In multivariate analysis, pleural fluid recurrence at 3 months had an adjusted hazard ratio of 2.54 (95% CI 1.73 to 4.40) for poor prognosis
  • In multivariate analysis, non-epithelioid histology had an adjusted hazard ratio of 2.81 (95% CI 1.82 to 5.09)
  • Clinical stage above II (adjusted HR 2.36), ECOG performance status 2 or greater (2.19), CRP above 5 mg/L (2.01) and platelet count above 400,000/mm3 (1.76) were also independent predictors of poor prognosis
  • Known occupational asbestos exposure was significantly associated with lower survival in univariate analysis (HR 1.42, p 0.031). It was not among the independent predictors identified in the multivariate analysis.
  • 3 of 172 patients had postoperative complications: 1 ictus cerebri and 2 pleural empyema
• The authors' conclusion: The authors concluded that persistent lung expansion after talc poudrage, with no fluid recurrence, was a stronger predictor of survival than clinical stage and other clinical variables in non-surgically resected MPM patients. They also concluded that effective pleurodesis selected a sub-group of patients with longer life expectancy. They called for further studies, including randomized prospective studies.
• Limitations the authors state:
  • The study was retrospective
  • Care after surgery, especially chemotherapy, varied between patients, which prevented rigorous survival analysis by chemotherapy

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma, Talc and vermiculite.

Medical terms in this study, explained in our Lexicon: Talc, Pleural Mesothelioma, Pleurodesis, Asbestos Exposure, Performance Status, Histological Subtype, Chemotherapy, Chest X-Ray.

Related studies

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• Lung function 22-35 years after treatment of idiopathic spontaneous pneumothorax with talc poudrage or simple drainage — P. Lange, J. Mortensen, et al. (1988)
• Relation between neutrophil/lymphocyte ratio and primary tumor metabolic activity in patients with malign pleural mesothelioma — B.A. Özyürek, Ö. Özmen, et al. (2018)
• Intrapleural talc for the prevention of recurrent pneumothorax — J.R. Milanez, F.S. Vargas, et al. (1994)
• Survival in patients with malignant pleural effusion undergoing talc pleurodesis — M. Hassan, R.M. Mercer, et al. (2019)
• A randomized controlled trial of the efficacy of cosmetic talc compared with iodopovidone for chemical pleurodesis — R. Agarwal, A.S. Paul, et al. (2011)

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