Pleurectomy/decortication, hyperthermic pleural lavage with povidone-iodine, prophylactic radiotherapy, and systemic chemotherapy in patients with malignant pleural mesothelioma: a 10-year experience

Our plain-English summary of Pleurectomy/decortication, hyperthermic pleural lavage with povidone-iodine, prophylactic radiotherapy, and systemic chemotherapy in patients with malignant pleural mesothelioma: a 10-year experience, by L. Lang-Lazdunski, A. Bille, S. Papa, et al (The Journal of Thoracic and Cardiovascular Surgery, 2015).

The study

• Authors: L. Lang-Lazdunski, A. Bille, S. Papa, S. Marshall, R. Lal, C. Galeone, D. Landau, J. Steele, J. Spicer
• Journal: The Journal of Thoracic and Cardiovascular Surgery
• Published: 2015;149(2):558-65; discussion 565-6
• Cited by: 73 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objectives: We evaluated the long-term results of pleurectomy/decortication (P/D), hyperthermic pleural lavage with povidone-iodine, prophylactic chest wall radiotherapy (21 Gy), and systemic chemotherapy in patients with malignant pleural mesothelioma.

Methods: A cohort of patients having surgery between January 2004 and December 2013 were retrospectively studied. All patients received prophylactic radiotherapy postoperatively and all were supposed to receive systemic chemotherapy, either preoperatively or as adjuvant therapy. Patients were reviewed at 30 days, then followed up 6-monthly. (18)F-FDG-PET-CT was used routinely to diagnose disease recurrence. Second-line therapies were administered when appropriate. Survival and prognostic factors were analyzed by the Kaplan-Meier method, log-rank test, and Cox regression analysis.

Results: One hundred two patients had P/D followed by prophylactic radiotherapy and were referred for adjuvant chemotherapy. Median age at operation was 64 years. Eighty-one patients (79.4%) were male; 57 patients (55.9%) had complete macroscopic resection. Thirty-day mortality was nil and 30 patients (29.4%) experienced postoperative complications. Seventy-three patients had epithelioid mesothelioma (71.5%). Sixty-eight patients (66.6%) had N0 disease. Ninety-six patients (94.1%) received the planned 4 to 6 chemotherapy cycles. At last follow-up, 49 patients were alive. Univariate analysis showed no significant difference when sex, age >70 years, nodal status, or prior chemotherapy were considered. The overall median survival was 32 months and 5-year survival rate was 23.1%. Median survival and 5-year survival rates were 35.0 months and 30.7% for epithelioid mesothelioma and 15 months and 7% for nonepithelioid mesothelioma, respectively (P = .0001). Median survival was 45.0 months for R0-R1 resection versus 17.4 months for R2 resection (P = .0001).

Conclusions: P/D, hyperthermic pleural lavage with povidone-iodine, prophylactic chest wall radiotherapy, and systemic chemotherapy is a safe and well-tolerated multimodality therapy.

Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

In plain English

This retrospective study followed 102 patients with malignant pleural mesothelioma operated on in London from January 2004 to December 2013. One surgeon performed pleurectomy/decortication, followed by a heated povidone-iodine chest rinse and preventive radiotherapy (21 Gy) to the incision, drain and port sites. Chemotherapy was given before surgery (14 patients) or after it (83 patients). The article does not report the patients' asbestos exposure. No patient died within 30 or 90 days of surgery, and 30 patients (29.4%) had complications. Median overall survival, counted from diagnosis, was 32 months (95% CI, 25.6-38.4), and the estimated 5-year survival rate was 23.1%. Median survival was 35.3 months (95% CI, 20.4-49.6) for epithelioid and 15.0 months (95% CI, 11.2-18.7) for nonepithelioid mesothelioma. It was 45.0 months (95% CI, 26.9-63.0) with complete macroscopic resection and 17.4 months (95% CI, 10.5-24.3) with incomplete (R2) resection. Of 76 patients who relapsed, 68 first relapsed on the same side of the chest. The authors concluded the regimen was safe and well tolerated, but noted the study was not randomized.

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 single-institution cohort study (case series) of patients given a multimodality treatment; no comparison group
• Who was studied: 102 patients with malignant pleural mesothelioma operated on by a single surgeon at Guy's & St Thomas Hospital, London, January 2004 to December 2013. 81 male and 21 female; median age 64.7 years (range 32-81); 73 epithelioid, 25 biphasic, 4 sarcomatoid. Only patients with performance status 0 to 1 were offered this treatment.
• Exposure: The article does not report asbestos exposure, fiber types or jobs. What was studied was a treatment: pleurectomy/decortication; hyperthermic pleural lavage (40 to 41 degrees) with 10% povidone-iodine diluted 1 in 10; prophylactic radiotherapy, 21 Gy in 3 daily fractions, to the thoracotomy, drain and port sites; and 4 to 6 cycles of platinum-based chemotherapy given before or after surgery.
• Main results:
  • No patient died within 30 days or 90 days of surgery. 30 of the 102 patients (29.4%) had postoperative complications, most often a persistent air leak lasting more than 5 days (17 patients).
  • For all 102 patients, survival was calculated from the date of diagnosis using the Kaplan-Meier method. Median overall survival was 32 months (95% CI, 25.6-38.4). Estimated survival rates were 87.2% at 1 year, 62.9% at 2 years and 23.1% at 5 years.
  • Median survival was 35.3 months (95% CI, 20.4-49.6) for patients with epithelioid mesothelioma and 15.0 months (95% CI, 11.2-18.7) for those with nonepithelioid mesothelioma. Estimated 5-year survival was 30.7% for epithelioid and 7% for nonepithelioid histology.
  • Median survival was 45.0 months (95% CI, 26.9-63.0) for patients with complete macroscopic resection (R0-R1, 57 patients) and 17.4 months (95% CI, 10.5-24.3) for those with incomplete macroscopic resection (R2, 45 patients). Estimated 5-year survival rates were 34.8% and 6.9%.
  • In multivariate analysis, only epithelioid histology (hazard ratio 4.27; 95% CI, 2.355-7.743) and complete resection (hazard ratio 3.4; 95% CI, 1.920-6.110) were independent prognostic factors.
  • Nodal status (N0 versus N1/N2) did not show a statistically significant difference in survival. Median survival was 32.3 months for N0 disease and 30.4 months for N1/N2 disease.
  • 76 patients were diagnosed with relapse. In 68 of these 76 (89.5%), the first recurrence was in the same-side pleural cavity or lung. No patient was diagnosed with chest wall tumor seeding at follow-up.
  • At last follow-up, 49 of the 102 patients were alive.
• The authors' conclusion: The authors concluded that this combination is a safe and well-tolerated multimodality scheme with low morbidity and mortality. They described it as an alternative to the classical trimodality regimen involving extrapleural pneumonectomy, and said further research is needed to reduce local recurrence after P/D.
• Limitations the authors state:
  • The study was not randomized, and patients were selected on the basis of prognostic factors. About 50% of referred patients were turned down for P/D.
  • All operations were done by a single surgeon. The authors regard this as a limitation because quality control is a potential problem in mesothelioma surgery.
  • The cohort was heterogeneous: 14 patients received chemotherapy before surgery rather than after it.
  • Four patients had pre-existing empyema at the time of surgery, which could have influenced their survival.
  • The lack of a nodal-status effect on survival is likely related to small numbers.
  • Because multiple therapies were used, the exact impact of the povidone-iodine lavage on outcomes cannot be known.
  • Quality of life data were not collected.

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), Chemotherapy, Pleural Mesothelioma, Adjuvant Therapy, PET-CT, Epithelioid, Mesothelioma, Median Survival.

Related studies

• Pleurectomy/decortication, hyperthermic pleural lavage with povidone-iodine followed by adjuvant chemotherapy in patients with malignant pleural mesothelioma — L. Lang-Lazdunski, A. Bille, et al. (2011)
• 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)
• Closing the stable door before the horse leaves — V. Acton (2015)
• Hyperthermic intraoperative pleural cisplatin chemotherapy extends interval to recurrence and survival among low-risk patients with malignant pleural mesothelioma undergoing surgical macroscopic complete resection — D.J. Sugarbaker, R.R. Gill, et al. (2013)

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