Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma

Our plain-English summary of Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma, by L. Lang-Lazdunski, A. Bille, R. Lal, et al (Journal of Thoracic Oncology, 2012).

The study

• Authors: L. Lang-Lazdunski, A. Bille, R. Lal, P. Cane, E. McLean, D. Landau, J. Steele, J. Spicer
• Journal: Journal of Thoracic Oncology
• Published: 2012;7(4):737-43
• Cited by: 137 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: To compare the outcomes of two different multimodality regimens involving neoadjuvant chemotherapy, extrapleural pneumonectomy (EPP) and adjuvant radiotherapy versus pleurectomy/decortication (P/D), hyperthermic pleural lavage with povidone-iodine, and adjuvant chemotherapy in patients with malignant pleural mesothelioma.

Methods: Nonrandomized prospective study of patients treated by multimodality therapy and operated on between January 2004 and June 2011. Second-line treatments were administered when appropriate. Survival and prognostic factors were analyzed by the Kaplan Meier method, log rank test, and Cox regression analysis.

Results: Twenty-five consecutive patients received neoadjuvant chemotherapy, 22 underwent EPP, and 17 received adjuvant radiotherapy. Over the same period, 54 consecutive patients underwent P/D and hyperthermic pleural lavage and received prophylactic radiotherapy and adjuvant chemotherapy. The 30-day mortality rate was 4.5%in the EPP group and nil in the P/D group. Fifteen patients (68%) in the EPP group and 15 (27.7%) in the P/D group experienced complications. There were no differences between the EPP and P/D groups for age, sex, histology, pathologic stage, and nodal status. Trimodality therapy was completed by 68%of the patients in the EPP group and 100%in the P/D group. Survival was significantly better in the P/D group: median survival was 23 months versus 12.8 months, 2-year survival was 49%versus 18.2 %, and 5-year survival was 30.1%versus 9%, respectively (p = 0.004). At multivariate analysis, epithelioid histology, P/D, and completeness of resection were independent prognostic factors.

Conclusions: In our experience, P/D, hyperthermic pleural lavage with povidone-iodine, and adjuvant chemotherapy were superior to neoadjuvant chemotherapy, EPP, and adjuvant radiotherapy.

In plain English

This nonrandomized prospective study from a London hospital compared two treatment programs for malignant pleural mesothelioma in patients operated on between January 2004 and June 2011 by one surgeon. In one group, 25 patients received chemotherapy. Of these, 22 then underwent extrapleural pneumonectomy (EPP: removal of the affected lung, pleura, pericardium and diaphragm), and 17 then received radiotherapy. The other 54 patients had pleurectomy/decortication (P/D: surgery aiming to remove all visible tumor), a heated povidone-iodine chest wash, preventive radiotherapy, then chemotherapy. Within 30 days, 4.5% of the EPP group and none of the P/D group died. Complications affected 68% of the EPP group and 27.7% of the P/D group. Measured from diagnosis, survival was significantly better with P/D (p = 0.004): median 23 versus 12.8 months, and five-year survival 30.1% versus 9%. The authors found no significant group differences in sex, tumor type, nodal status or stage. However, 9 of 54 P/D patients and no EPP patients were over 70. Chemotherapy timing and number of cycles also differed. The authors concluded that P/D should become the standard operation within multimodality therapy.

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: Nonrandomized prospective study comparing two multimodality treatment regimens at a single institution
• Who was studied: Patients with malignant pleural mesothelioma referred for multimodality therapy at Guy's & St Thomas' Hospital, London, between January 2004 and June 2011. In the EPP group, 25 consented and received neoadjuvant chemotherapy, and 22 underwent EPP (3 abandoned at surgery). In the P/D group, 61 had P/D, 7 were excluded, and 54 were analyzed. The article gives no information on the patients' asbestos exposure.
• Exposure: Two treatment regimens were compared. The first was neoadjuvant chemotherapy (cisplatin with gemcitabine or pemetrexed), then extrapleural pneumonectomy, then adjuvant radiotherapy (54 Gy). The second was pleurectomy/decortication with hyperthermic pleural lavage with povidone-iodine, then prophylactic radiotherapy (21 Gy in three fractions), then adjuvant chemotherapy. No asbestos exposure data are reported.
• Main results:
  • In the EPP group, 25 patients received neoadjuvant chemotherapy, 22 underwent EPP, and 17 received adjuvant radiotherapy
  • 30-day mortality was 4.5% in the EPP group (one intraoperative death from aortic rupture) and nil in the P/D group
  • Complications occurred in 15 patients (68%) in the EPP group and 15 (27.7%) in the P/D group
  • In the EPP group, 17 patients (68%) completed the full multimodality treatment. In the P/D group, 52 patients (96.3%) received the planned four to six cycles of adjuvant chemotherapy and completed the full regimen.
  • Survival was measured from diagnosis. In the overall comparison it was significantly better in the P/D group than in the EPP group (p = 0.004): median 23 versus 12.8 months; 1-year 81.9% versus 54.5%; 2-year 49% versus 18.2%; 5-year 30.1% versus 9%.
  • In patients with epithelioid tumors, median survival was 28.9 months with P/D versus 12.8 months with EPP (p = 0.018)
  • In patients with nonepithelioid histology, median survival was 18.3 months with P/D versus 8.8 months with EPP. The authors called this marginally better survival after P/D (p = 0.07).
  • In multivariate analysis, three factors were independent prognostic factors: type of operation (table: P/D vs. EPP, hazard ratio 3.6, 95% CI 1.7 to 7.4), histology (hazard ratio 2.15, 95% CI 1.15 to 4.0), and complete macroscopic resection (hazard ratio 2.5, 95% CI 1.1 to 5.7). Nodal involvement and pathological stage were not.
  • No patient in the EPP group was older than 70, compared with 9 of 54 in the P/D group (p = 0.04)
• The authors' conclusion: The authors concluded that EPP resulted in higher mortality and morbidity and that P/D gave significantly better survival in their experience. They proposed that P/D become the standard surgical procedure within multimodality therapy for malignant pleural mesothelioma. They also called for a randomized trial of multimodality therapy with P/D versus no P/D.
• Limitations the authors state:
  • Patients were not randomized to EPP or P/D
  • Chemotherapy differed between groups (3 cycles versus 4 to 6), which the authors recognized could have influenced survival
  • This was a single-institution series, with limitations compared with a large multicenter study
  • The authors attributed the lack of prognostic significance for stage and nodal status to the small number of patients

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), Extrapleural Pneumonectomy (EPP), Pleural Mesothelioma, Neoadjuvant Chemotherapy, Chemotherapy, Multimodal Therapy, Histology, Trimodality Therapy.

Related studies

• Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma — S. Hasegawa (2014)
• 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)
• 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)
• 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)
• Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma — E. Taioli, A.S. Wolf, et al. (2015)
• Extrapleural Pneumonectomy Versus Pleurectomy/Decortication for Malignant Pleural Mesothelioma — N. Zhou, D.C. Rice, et al. (2022)

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