Pleurectomy decortication for mesothelioma: The procedure of choice when possible

Our plain-English summary of Pleurectomy decortication for mesothelioma: The procedure of choice when possible, by R.M. Flores (The Journal of Thoracic and Cardiovascular Surgery, 2016).

The study

• Author: R.M. Flores
• Journal: The Journal of Thoracic and Cardiovascular Surgery
• Published: 2016;151(2):310-2
• Type of article: Editorial
• Cited by: 15 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Summary of the article

In this editorial, a thoracic surgeon at the Icahn School of Medicine at Mount Sinai, New York, addressed which operation offers more benefit to patients with mesothelioma: extrapleural pneumonectomy (EPP) or pleurectomy decortication (PD). He set aside the question of surgery versus medical therapy. The author described how his view had changed since his training in the mid 1990s, when he favoured EPP. He argued that neither operation achieves a true R0 resection. He also argued that the data supporting EPP came mainly from biased retrospective studies of highly selected patients, and that survival in these studies tended to worsen as more patients were added. He judged the MARS trial (24 patients in the EPP arm and 26 in the nonsurgical arm, with 18% operative mortality) too underpowered to show that EPP harms patients. In his view, it showed only that such a randomized trial is not feasible. He proposed a 5-year survival of 15% in patients without surgical resection as the minimum standard for comparing treatments. He cited a study of 663 patients (385 EPP, 278 PD) in which EPP was associated with worse survival (hazard ratio 1.4) after controlling for histologic type, stage, multimodality treatment and sex. He concluded that PD preserves more lung, has lower morbidity and mortality, and gives similar or better survival. He was not ready to abandon EPP completely.

PubMed has no abstract for this study, and the article doesn't print one. We wrote this summary from the full article with the help of AI. It is not the authors' wording.

In plain English

This was an editorial, an opinion piece by a thoracic surgeon. It was not a new study, reported no new patient data, and did not discuss asbestos exposure. The author asked which operation offers more benefit for mesothelioma: extrapleural pneumonectomy (EPP) or pleurectomy decortication (PD). The author argued that most data supporting EPP came from biased retrospective studies of highly selected patients. The author called the MARS randomized trial severely underpowered, with 24 patients in the EPP arm and 26 in the nonsurgical arm, and doubted that its 18% operative death rate was the true risk of EPP. The author reproduced a table from an earlier study by Flores and colleagues of 663 patients with malignant pleural mesothelioma. In that study's multivariate model, EPP had a hazard ratio of 1.4 (95% confidence interval 1.18 to 1.69) compared with PD. The author acknowledged that the study was retrospective and subject to surgeon selection bias. The author concluded that PD appears to provide the most benefit and least harm, but was not ready to abandon EPP completely.

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: Editorial (opinion piece); no original data
• Who was studied: No patients were studied. The editorial discusses surgery for mesothelioma in general.
• Exposure: Not asbestos. The comparison is between two surgical procedures: extrapleural pneumonectomy (EPP) and pleurectomy decortication (PD).
• Main results:
  • The author argued that the data supporting EPP come mainly from biased retrospective studies of highly selected patients.
  • The author described the MARS trial (another study) as severely underpowered, with 24 patients in the EPP arm and 26 in the nonsurgical arm.
  • The author questioned whether the 18% operative death rate reported in the MARS trial was the true operative risk of EPP.
  • In a table reproduced from an earlier study by Flores and colleagues of 663 patients with malignant pleural mesothelioma, EPP had a hazard ratio of 1.4 (95% CI 1.18 to 1.69, p less than .001) compared with PD in a multivariate model.
• The authors' conclusion: The author concluded that PD appears to give the most benefit and least harm to mesothelioma patients undergoing surgery, but was not ready to abandon EPP completely.
• Limitations the authors state:
  • The author acknowledged that the cited head-to-head comparison was retrospective, subject to surgeon selection bias, and had varied adjuvant treatment.
  • The question of surgery versus medical therapy was outside the editorial's scope.

Topics

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

Medical terms in this study, explained in our Lexicon: Mesothelioma, Extrapleural Pneumonectomy (EPP), Surgical Resection, Hazard Ratio.

Related studies

• Is pleurectomy and decortication superior to palliative care in the treatment of malignant pleural mesothelioma? — I. Zahid, S. Sharif, et al. (2011)
• What is the best approach for surgery of malignant pleural mesothelioma? It is to put our efforts into obtaining trustworthy evidence for practice — T. Treasure (2016)
• Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma — S. Hasegawa (2014)
• Quality of life after radical pleurectomy decortication for malignant pleural mesothelioma — N.M. Mollberg, Y. Vigneswaran, et al. (2012)
• 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)

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