Prognostic factors for survival after surgical palliation of malignant pleural effusion

Our plain-English summary of Prognostic factors for survival after surgical palliation of malignant pleural effusion, by J.E. Pilling, M.E. Dusmet, G. Ladas, et al (Journal of Thoracic Oncology, 2010).

The study

• Authors: J.E. Pilling, M.E. Dusmet, G. Ladas, P. Goldstraw
• Journal: Journal of Thoracic Oncology
• Published: 2010;5(10):1544-50
• Cited by: 50 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: To investigate prognostic factors for patient survival after surgical palliation of malignant pleural effusion (MPE).

Method: We reviewed 278 consecutive nonoverseas patients (108 men, median age: 60 years [range 26-89]) undergoing 310 surgical procedures for palliation of MPE over a 72-month period. There were 195 thoracoscopic talc pleurodesis, 39 pleuroperitoneal shunts, 38 pleurodesis by an intercostal drain, 29 pleural biopsies alone, and nine long-term drains. Referring physicians provided survival data. The significance of prognostic factors was examined with the log-rank test (Kaplan-Meier), those significant entered a Cox logistic multivariate regression analysis.

Results: Follow-up was complete until death (following 264 procedures) and for a median 648 days (range 173-2135) for surviving patients. Overall median postoperative survival was 211 days (95% confidence interval: 169-253). Survival was not significantly different for tumor type or method of palliation. In univarate analysis, preoperative leucocytosis, hypoxemia, raised alanine transaminase, body mass index below 18 and hypoalbuminemia were associated with a significantly reduced postoperative survival. In multivariate analysis, leucocytosis (p < 0.0001), hypoxemia (p = 0.014), and hypoalbuminemia (p < 0.0001) maintained significance.

Conclusions: The survival reported demonstrates the necessity of an active approach to palliation of MPE. The identification of prognostic factors will assist the choice of palliative technique. In addition, an appreciation of the influence of selection on survival after surgical palliation of malignant pleural mesothelioma, especially that of unforeseen prognostic factors, is useful when evaluating the results of aggressive treatment such as chemoradiotherapy and radical surgery for these diseases.

In plain English

This retrospective study from the Royal Brompton Hospital, London, covered 278 consecutive nonoverseas patients (108 men, median age 60) who had 310 procedures in 1999 to 2004 for malignant pleural effusion, which is fluid around the lung caused by cancer. Breast cancer and malignant pleural mesothelioma were the most common cancers. Asbestos exposure was not studied. Overall median survival after the procedure was 211 days (95% confidence interval 169 to 253). Survival did not differ significantly by tumor type or by procedure. In the main analysis, three results of routine tests before surgery remained linked to shorter survival: a high white cell count, low blood oxygen and low albumin. The 23 with all three had a median survival of 42 days (95% CI 23 to 61), against 702 days (473 to 931) for the 39 with none. In the mesothelioma group (79 procedures; Table 1 lists 77 patients), median survival was 297 days (95% CI 234 to 360). The three factors split them into groups with different survival, but not significantly. The authors noted the study could show only associations. They concluded the factors could help counseling and the choice of palliation method.

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 review of consecutive patients treated at one thoracic surgery unit
• Who was studied: 278 consecutive nonoverseas patients (108 men, median age 60, range 26 to 89) who had 310 procedures for malignant pleural effusion at the Department of Thoracic Surgery, Royal Brompton Hospital, London, from January 1999 to December 2004. These were patients referred to a thoracic surgical unit. Table 1 lists 81 patients with breast cancer, 77 with malignant pleural mesothelioma, 37 with lung cancer and 25 with ovarian cancer, among other cancers.
• Exposure: Not asbestos. The factors studied were features available before surgery: demographics, arterial blood gases, blood chemistry and blood counts, and body mass index. Tumor type and type of palliative procedure were also studied. The procedures were 195 thoracoscopic talc pleurodeses, 39 pleuroperitoneal shunts, 38 pleurodeses through a drain, 29 biopsies alone and nine long-term drains.
• Main results:
  • For all patients, overall median survival after the procedure was 211 days (95% CI 169 to 253).
  • Nine patients (2.9%) died in hospital after the palliative procedures.
  • Survival did not differ significantly by tumor type (p = 0.546). Mesothelioma and breast cancer showed a trend toward longer survival that was not statistically significant.
  • Survival did not differ significantly by type of palliative procedure (p = 0.5589).
  • In univariate analysis, five preoperative factors were associated with significantly reduced survival: leucocytosis, hypoxemia, raised alanine transaminase, body mass index below 18 and hypoalbuminemia.
  • In multivariate analysis, three factors remained significant: leucocytosis, hypoxemia and hypoalbuminemia. Sex, age, weight loss over 10%, anemia, creatinine and raised alkaline phosphatase were not significant.
  • Table 6 gives median survival by number of these factors. With none: 702 days (95% CI 473 to 931, n = 39). With one or two: 200 days (95% CI 111 to 289, n = 74). With all three: 42 days (95% CI 23 to 61, n = 23). The table's groups add up to 136, not to all patients.
  • The mesothelioma group was followed for a median of 1114 days, with 64 deaths. Median survival was 297 days (95% CI 234 to 360 in the text; 236 to 358 in Table 3). The results text calls this group 79 patients, but Table 1 lists 77 mesothelioma patients who had 79 procedures.
  • In mesothelioma, the three factors were not significantly associated with survival (p = 0.06). Median survival with no factors was 438 days (n = 15). With one or two factors it was 215 days (n = 39). With all three it was 65 days (n = 3).
• The authors' conclusion: The authors concluded that low albumin, low blood oxygen and a raised white cell count are easily measured by routine tests before surgery. They wrote that these results could help patient counseling and the choice of palliation method. They also wrote that a median survival of 211 days justified an active approach to palliation.
• Limitations the authors state:
  • The study was retrospective, so the authors could claim only an association between the factors and poor prognosis.
  • The population was patients referred to a thoracic surgical unit and was not specific to one disease.
  • Finding no effect of tumor type may reflect too few patients in each group.
  • Complete information on cancer treatment received outside the institution was not available.
  • The number of failed procedures may be underestimated.
  • Performance status was not routinely recorded, so it was not analyzed.
  • Pleural fluid glucose and pH, and the extent of disease, were not analyzed.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Effusion, Talc Pleurodesis, Pleurodesis, confidence interval, Multivariate Analysis, Palliative Care, Pleural Mesothelioma.

Related studies

• Survival in patients with malignant pleural effusion undergoing talc pleurodesis — M. Hassan, R.M. Mercer, et al. (2019)
• Thoracoscopic palliative treatment of malignant pleural effusions: results in 273 patients — K. Arapis, R. Caliandro, et al. (2006)
• The efficacy of pemetrexed and bevacizumab intrapleural injection for malignant pleural mesothelioma-mediated malignant pleural effusion — D. Chen, X. Li, et al. (2014)
• Outcome and prognostic factors of pleural mesothelioma after surgical diagnosis and/or pleurodesis — M. Baud, S. Strano, et al. (2013)
• Survivin is a negative prognostic factor in malignant pleural effusion — E. Arellano-Orden, B. Romero-Romero, et al. (2018)
• Prognostic factors in malignant pleural mesothelioma: role of talc pleurodesis — B.S. Al-Alao, H. Parissis, et al. (2012)

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