Pleurectomy/decortication, hyperthermic pleural lavage with povidone-iodine followed by adjuvant chemotherapy in patients with malignant pleural mesothelioma

Our plain-English summary of Pleurectomy/decortication, hyperthermic pleural lavage with povidone-iodine followed by adjuvant chemotherapy in patients with malignant pleural mesothelioma, by L. Lang-Lazdunski, A. Bille, E. Belcher, et al (Journal of Thoracic Oncology, 2011).

The study

• Authors: L. Lang-Lazdunski, A. Bille, E. Belcher, P. Cane, D. Landau, J. Steele, H. Taylor, J. Spicer
• Journal: Journal of Thoracic Oncology
• Published: 2011;6(10):1746-52
• Cited by: 42 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: Malignant pleural mesothelioma is a fatal neoplasm related to asbestos exposure. We investigated the effects of pleurectomy/decortication (P/D), hyperthermic pleural lavage with povidone-iodine and adjuvant chemotherapy in patients with malignant pleural mesothelioma.

Patients And Methods: Observational prospective study of patients referred for multimodality therapy and operated on at our institution between October 2004 and May 2010. Thirty-six selected patients underwent P/D and hyperthermic pleural lavage, prophylactic radiotherapy, and adjuvant chemotherapy. All patients were reviewed at 4 weeks and then 6 monthly in the outpatient clinic, with positron-emission tomography-computed tomography. Second-line treatments were administered when appropriate.

Results: Thirty-day mortality was nil. Nine patients experienced postoperative complications: persistent air leak (n = 5, 13.9%), chylothorax requiring surgical intervention (n = 4, 11%), and adult respiratory distress syndrome (n = 1, 3.9%). Fourteen of 36 patients were alive at last follow-up (median follow-up: 33 months, range: 12-63 months). Ten patients were alive with no evidence of disease recurrence, four patients were alive with disease recurrence, and 22 patients had died of disease progression. Overall median survival (Kaplan-Meier) was 24 months (95% confidence interval: 18.5-29.4 months). One-year survival was 91.7%, and 2-year survival was 61%. Patients undergoing complete macroscopical resection (R0-R1) had a significantly better survival than those undergoing an incomplete macroscopical resection (R2) (median overall survival: 32 months versus 18.9 months, p = 0.012).

Conclusion: In our experience, P/D combined with hyperthermic pleural lavage with povidone-iodine and adjuvant chemotherapy is a well-tolerated multimodality treatment associated with low morbidity and mortality. This multimodality treatment compares favorably with classical trimodality regimens involving chemotherapy, extrapleural pneumonectomy, and adjuvant radiotherapy, in our experience. Study limitations include small sample size, nonrandomization, and patient selection bias.

In plain English

This observational prospective study came from the thoracic surgery unit at Guy's and St Thomas Hospital in London. It described 36 selected patients with malignant pleural mesothelioma operated on between 2004 and May 2010. They received pleurectomy/decortication, a warm pleural wash with diluted povidone-iodine, preventive radiotherapy to the wound and drain sites, and chemotherapy after surgery. The study did not report patients' asbestos exposure. No patient died within 30 days of surgery. Five patients had a persistent air leak, four had chylothorax needing further surgery, and one had adult respiratory distress syndrome. At a median follow-up of 33 months, 14 of 36 patients were alive and 22 had died of disease progression. Median overall survival was 24 months (95% confidence interval 18.5 to 29.4). Median survival was 32 months for the 20 patients whose visible tumor was completely removed and 18.9 months for the 16 with incomplete removal, a statistically significant difference. The authors concluded the treatment was well tolerated, with low morbidity and mortality. They noted the small sample, lack of randomization and patient 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: Observational prospective study (single-institution case series of a surgical multimodality treatment; no comparison group, not randomized)
• Who was studied: Forty-one patients had pleurectomy/decortication by a single surgeon at Guy's and St Thomas Hospital, London, between November 2004 and May 2010. Five were excluded (two for empyema after talc pleurodesis, three for prior chemotherapy or intrapleural gene therapy), leaving 36 patients with malignant pleural mesothelioma. Mean age was 62.2 years (range 46 to 73) and two were women. Histology: 24 epithelioid (66.7%), 10 biphasic (27.8%), 2 sarcomatoid (5.5%).
• Exposure: This study examined a treatment, not asbestos exposure. Treatment was pleurectomy/decortication, then hyperthermic pleural lavage (40 to 41°C) with sterile water mixed with 10% povidone-iodine, prophylactic radiotherapy (21 Gy in three fractions) to thoracotomy, drain and port sites, and adjuvant chemotherapy (gemcitabine and cisplatin before 2007, pemetrexed and cisplatin thereafter; 4 to 6 cycles intended). No fiber types or asbestos exposure data were reported.
• Main results:
  • There was no 30-day mortality among the 36 patients.
  • Postoperative complications: 5 patients (13.9%) had a persistent air leak; 4 patients (11.1%) had chylothorax requiring thoracotomy or video-assisted thoracoscopic surgery; 1 patient had adult respiratory distress syndrome (printed as 3.9%).
  • Thirty-five patients (97.2%) received the planned 4 to 6 chemotherapy cycles and completed the full regimen.
  • At last follow-up (median 33 months, range 12 to 63 months), 14 of 36 patients were alive: 10 with no evidence of recurrence and 4 with recurrence. The other 22 patients had died of disease progression.
  • Overall median survival (Kaplan-Meier) for the 36 patients was 24 months (95% confidence interval 18.5 to 29.4 months).
  • For all 36 patients, one-year survival was 91.7% and two-year survival was 61%.
  • Twenty patients (55.6%) had complete macroscopic resection (R0 to R1). Sixteen (printed as 45.4%) had incomplete macroscopic resection (R2).
  • With complete macroscopic resection, 1-year survival was 100%, 2-year survival 83.9% and median survival 32 months. With incomplete resection, 1-year survival was 81.2%, 2-year survival 31.6% and median survival 18.9 months. The difference was reported as statistically significant (p-value 0.012).
  • In univariate analysis, survival did not differ significantly by sex, age, histological subtype (epithelioid versus biphasic/sarcomatoid) or side of surgery.
  • No patient was diagnosed with chest wall tumor seeding at follow-up.
• The authors' conclusion: The authors concluded that, in their experience, this combined treatment was well tolerated and associated with low morbidity and mortality. They said it could be an alternative to the classical trimodality regimen involving extrapleural pneumonectomy if their results were confirmed in larger trials and by other groups. They called for further studies comparing it with chemotherapy only.
• Limitations the authors state:
  • The authors acknowledged a small sample size and lack of randomization.
  • The authors acknowledged patient selection bias based on prognostic factors.
  • The authors said they could not judge the effect of the povidone-iodine lavage on survival in their short series.
  • The authors did not collect quality of life data.

Topics

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

Medical terms in this study, explained in our Lexicon: Pleurectomy/Decortication (P/D), Chemotherapy, Pleural Mesothelioma, Neoplasm, Asbestos Exposure, Multimodal Therapy, Disease Progression, Median Survival.

Related studies

• Pleurectomy/decortication, hyperthermic pleural lavage with povidone-iodine, prophylactic radiotherapy, and systemic chemotherapy in patients with malignant pleural mesothelioma: a 10-year experience — L. Lang-Lazdunski, A. Bille, et al. (2015)
• Povidone iodine: the new solution for mesothelioma? — V.W. Rusch (2015)
• Induction chemotherapy, extrapleural pneumonectomy, and adjuvant radiotherapy for malignant pleural mesothelioma: experience of Guy's and St Thomas' hospitals — A. Bille, E. Belcher, et al. (2012)
• Local and systemic exposure of cisplatin during hyperthermic intrathoracic chemotherapy perfusion after pleurectomy and decortication for treatment of pleural malignancies — M. Ried, T. Potzger, et al. (2013)
• Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma — L. Lang-Lazdunski, A. Bille, et al. (2012)
• Antineoplastic activity of povidone-iodine on different mesothelioma cell lines: results of in vitro study — A. Fiorelli, F. Pentimalli, et al. (2014)

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