Pleuropneumonectomy in the management of diffuse malignant mesothelioma of the pleura. Experience with 29 patients

Our plain-English summary of Pleuropneumonectomy in the management of diffuse malignant mesothelioma of the pleura. Experience with 29 patients, by E.G. Butchart, T. Ashcroft, W.C. Barnsley, et al (Thorax, 1976).

The study

• Authors: E.G. Butchart, T. Ashcroft, W.C. Barnsley, M.P. Holden
• Journal: Thorax
• Published: 1976;31(1):15-24
• Cited by: 405 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text
• In J-M's library: Johns-Manville's company medical library held a copy (J-M no. 001107).

Abstract

An analysis is made of the results of pleuropneumonectomy for diffuse malignant pleural mesothelioma in 29 patients and a comparison is made with the results of non-surgical treatment in a further 17 patients. A system of tumour staging is proposed, and the results are correlated with tumour stage and with histological type. Pleuropneumonectomy does not appear materially to affect the course of the disease in cases of mixed epithelial and mesenchymal histological type. However, stage I cases of pure epithelial histological type appear to carry a better prognosis, especially those whose histological structure consists entirely of abundant oedematous mucoid stroma with loosely arranged tumour cells. It is suggested therefore that only epithelial cases should be subjected to pleuropneumonectomy. Means of reducing operative mortality are discussed and alternative methods of treatment described.

In plain English

This article described 29 patients (20 men, 9 women) with diffuse malignant mesothelioma of the pleura who underwent pleuropneumonectomy, removal of the lung with the pleura, between 1959 and 1972. They were compared with 17 patients treated without surgery. Most surgical patients reported past asbestos contact; fiber types were not stated. Nine of the 29 died in hospital after the operation (31%), and only three (10.3%) survived two years or longer. Two of these were alive without recurrence when the article was written. Hospital deaths rose sharply over age 60; the authors judged seven of the nine preventable. Among patients surviving operation, those with epithelial tumours survived significantly better than those with mixed tumours, but only at six months. With operative deaths excluded, survival from first symptom to death did not differ significantly between surgical and non-surgical patients, overall or by histological type. The authors concluded that the operation was not justified for every case. They added that, if hospital deaths and complications could be reduced, it seemed justified for stage I tumours of pure epithelial type.

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: Case series of surgically treated patients at one cardiothoracic department, compared with a non-surgical group whose diagnoses were confirmed at necropsy. The authors also proposed a staging system.
• Who was studied: 29 surgical patients (20 men, 9 women; age range 35 to 63) operated on between 1959 and 1972 at the Department of Cardiothoracic Surgery, Shotley Bridge General Hospital (Tyneside area), plus 17 non-surgical patients (16 men, 1 woman), all with diffuse malignant pleural mesothelioma.
• Exposure: Most surgical patients reported a history of asbestos contact, often more than 30 years before symptoms began; fiber types were not specified. The study compared pleuropneumonectomy with non-surgical treatment (pleural aspiration, intrapleural cytotoxic drugs, intrapleural radioactive gold, radiotherapy, or no recorded treatment).
• Main results:
  • In the 29 surgical patients, hospital mortality was 31% (9 deaths), and only three patients (10.3%) survived two years or longer.
  • Two of the three surgical patients who survived two years or longer were alive and well with no evidence of recurrence. Both had epithelial type A tumours.
  • Hospital mortality after surgery rose markedly over age 60. Table IV shows 4 deaths among 8 patients aged 60 to 69.
  • The authors considered seven of the nine hospital deaths preventable by better case selection, surgical technique or postoperative care.
  • The total complication rate in the surgical series was 44.8%. This covered the 9 deaths plus 4 other patients with significant complications.
  • Among patients who survived operation, survival was significantly higher in the epithelial group than in the mixed epithelial and mesenchymal group (p less than 0.01), but only at six months after operation.
  • Among surgical patients with stage I tumours, significantly more of the epithelial group survived one year or more.
  • Among surgical patients with epithelial tumours, significantly more of those with type A tumours survived more than two years (p less than 0.05).
  • In the non-surgical group, three of the seven patients with epithelial tumours (42.9%) lived three years or longer, and no mixed or mesenchymal case survived longer than two years. For the group as a whole, survival did not differ significantly between epithelial and mixed or mesenchymal tumours.
  • Survival from first symptom to death showed no statistically significant difference between surgical and non-surgical patients, either overall or within each histological type. Operative deaths were excluded from this comparison.
• The authors' conclusion: The authors concluded that pleuropneumonectomy could not be justified as the treatment of choice for all cases. They concluded that, if hospital morbidity and mortality could be reduced, it seemed justified for stage I cases of pure epithelial type.
• Limitations the authors state:
  • Records for the non-surgical patients were incomplete and numbers were small, so no specific non-surgical treatment was assessed.
  • There was not enough information to compare complications between surgical and medically treated patients.
  • Small numbers made statistical analysis of tumour stage at necropsy unhelpful.
  • Only three type A epithelial tumours were seen, and the authors stated that a larger series of epithelial cases is needed to clarify the link between type A and prognosis.

Topics

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

Medical terms in this study, explained in our Lexicon: Malignant Mesothelioma, Pleura, Pleural Mesothelioma, Staging, Prognosis.

Related studies

• Acute cardiac herniation after radical pleuropneumonectomy — R.J. Self, R.S. Vaughan (1999)
• Three decades of experience in the surgical multi-modality management of pleural mesothelioma — H. Luckraz, M. Rahman, et al. (2010)
• Should we continue to offer extrapleural pneumonectomy to selected mesothelioma patients? A single center experience comparing surgical and non-surgical management — M. Baud, A. Bobbio, et al. (2014)
• Postoperative morbidity and mortality after pneumonectomy: a 30-year experience of 2064 consecutive patients — C. Pricopi, P. Mordant, et al. (2015)
• Unilateral pulmonary artery pre-operative occlusion test: technical feasibility and safety prior to pneumonectomy or pleuropneumonectomy for malignancy — M. Shimohira, T. Hashizume, et al. (2018)
• Multimodal management of malignant pleural mesothelioma: where are we today? — P.E. Van Schil, I. Opitz, et al. (2014)

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