Prolonged survival and novel prognostic factors in women with pleural mesothelioma treated with extended pleurectomy decortication

Our plain-English summary of Prolonged survival and novel prognostic factors in women with pleural mesothelioma treated with extended pleurectomy decortication, by M. Lapidot, E. Mazzola, R. Bueno (Translational Lung Cancer Research, 2024).

The study

• Authors: M. Lapidot, E. Mazzola, R. Bueno
• Journal: Translational Lung Cancer Research
• Published: 2024;13(4):811-820
• Cited by: 5 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Pleural mesothelioma (PM) is an uncommon and extremely aggressive malignancy associated with past exposure to asbestos. The low representation of women among PM patients is likely due to differences in occupational asbestos exposure. Due to the controversial role of female sex as a prognostic factor in PM, the study aims to evaluate the survival of females treated with lung-sparing surgery. We present a cohort of 114 consecutive female patients with PM who underwent intended extended pleurectomy decortication (ePD) over 11 years in a high-volume single institution.

Methods: All women from 2007-2017 who underwent intended ePD were enrolled in the study. Data on clinical, operative, and outcome were collected. Kaplan-Meier estimators and log-rank tests were employed to assess the overall survival, and Cox regression models were utilized to analyze prognostic factors.

Results: During the study period, 454 patients underwent thoracotomy with intended ePD in a single institution. There were 114 females (25%), and macroscopic complete resection (MCR) was achieved in 97 (85.1%). The median age was 65 years, histology was epithelioid in 81 (71.0%), biphasic in 31 (27.2%), and sarcomatoid in 2 (1.8%). The 30- and 90-day mortality were 3.5% and 6.1%, respectively. Median survival in females was 38 months, and 5-year survival was 28.2%. The median survival and 5-year survival rate for patients with epithelioid histology and MCR were 44.4 months and 36.4%, respectively. In a univariate analysis, several factors were found to be associated with patient overall survival including MCR [hazard ratio (HR): 0.3, P<0.001], early T status (HR: 1.6, P=0.03), adjuvant therapy (HR: 0.5, P=0.006), intraoperative heated chemotherapy (IOHC) (HR: 0.8, P=0.03), age (HR: 1.02, P=0.03) and epithelioid histology (HR: 0.5, P=0.009).

Conclusions: For women with epithelioid PM undergoing intended ePD within a multimodal setting, prolonged survival is anticipated.

2024 Translational Lung Cancer Research. All rights reserved.

In plain English

This study reviewed records of 454 consecutive patients at Brigham and Women's Hospital in Boston who had surgery between 2007 and 2017 intended to be extended pleurectomy decortication, a lung-sparing operation for pleural mesothelioma. It focused on the 114 women (25.1%). The article gives no information about the patients' asbestos exposure. All visible tumor was removed in 97 women (85.1%). Of the women, 3.5% died within 30 days and 6.1% within 90 days. Median survival for the women was 38 months, and 28.2% were alive at 5 years. For women with epithelioid tumors whose visible tumor was fully removed, the figures were 44.4 months and 36.4%. Among women, in an analysis of each factor separately, survival was associated with complete removal, tumor type, age, tumor stage, chemotherapy after surgery and heated chemotherapy during surgery. In the whole surgical group, minus two patients lacking follow-up data, women survived longer than men after accounting for other factors. The authors concluded that women with epithelioid pleural mesothelioma benefit more than men from this surgery as part of combined treatment. They noted that the study was retrospective and came from a single institution.

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 analysis of a prospectively collected surgical database at a single institution
• Who was studied: 454 consecutive patients who underwent thoracotomy with intended extended pleurectomy decortication for pleural mesothelioma at Brigham and Women's Hospital, Boston, 2007 to 2017. Two patients from overseas were excluded from survival analysis for lack of follow-up data. The analysis focused on the 114 women (25.1%), whose median age was 65 years.
• Exposure: Asbestos exposure was not assessed; the article reports no exposure information for these patients. The study examined treatment: intended extended pleurectomy decortication, intraoperative heated chemotherapy with cisplatin, and postoperative chemotherapy (platinum-based chemotherapy and pemetrexed).
• Main results:
  • Women (n=114): median survival 38 months; 5-year survival 28.2%
  • Women: 30-day mortality 3.5% and 90-day mortality 6.1%
  • Women in whom macroscopic complete resection was achieved (97, 85.1%): median survival 40.5 months (95% CI 29.1 to 53.7) and 5-year survival 31.8% (95% CI 22.2 to 45.4%). Women without complete resection: median survival 4.6 months.
  • Women with epithelioid histology and macroscopic complete resection: median survival 44.4 months; 5-year survival 36.4%
  • In univariate analysis among women (each factor examined separately), overall survival differed significantly by age as a continuous factor (P=0.03), epithelioid histology (P=0.009), macroscopic complete resection (P<0.001; HR 0.3, 95% CI 0.2 to 0.56), T status (P=0.03), adjuvant therapy (P=0.006; HR 0.5, 95% CI 0.3 to 0.86) and intraoperative heated chemotherapy (P=0.03; HR 0.8, 95% CI 0.32 to 0.9).
  • Among women, neoadjuvant treatment, N status and preoperative percentage FEV1 were not associated with overall survival.
  • Whole surgical cohort, excluding two patients without follow-up data (Figure 1 shows 114 females and 338 males at risk): in the multivariable Cox model (Table 2, labeled N=454), males had a hazard ratio of 1.5 (P=0.006) compared with females. The authors state females survived significantly longer than males independent of the other factors in the model.
  • Median progression-free survival was 455 days for females versus 310 days for males (HR 1.5, P=0.001).
  • There was no significant difference in survival between males and females with non-epithelioid mesothelioma (Figure 5, biphasic, P=0.18).
• The authors' conclusion: The authors concluded that women with epithelioid pleural mesothelioma benefit more than men from extended pleurectomy decortication as part of a multimodal approach, with a median survival of almost 4 years and low 30- and 90-day mortality. They wrote that the findings support an aggressive multimodality approach including this surgery in women with epithelioid mesothelioma.
• Limitations the authors state:
  • The study was retrospective.
  • The study came from a single institution, so the findings may not be generalizable and may vary at other institutions.
  • The finding on intraoperative heated chemotherapy should be interpreted cautiously, because most patients received it.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Asbestos Exposure, Overall Survival, Thoracotomy, Histology, Epithelioid, Biphasic Mesothelioma, Sarcomatoid.

Related studies

• Extended Pleurectomy-Decortication-Based Treatment for Advanced Stage Epithelial Mesothelioma Yielding a Median Survival of Nearly Three Years — J.S. Friedberg, C.B. Simone, et al. (2017)
• Extended Pleurectomy and Decortication for Malignant Pleural Mesothelioma Is an Effective and Safe Cytoreductive Surgery in the Elderly — T. Williams, H. Duraid, et al. (2015)
• Effects of extended pleurectomy and decortication on quality of life and pulmonary function in patients with malignant pleural mesothelioma — D. Burkholder, D. Hadi, et al. (2015)
• Extended pleurectomy decortication for thymoma with pleural dissemination — N. Imanishi, Y. Nabe, et al. (2019)
• Thoracic shaping technique to avoid residual space after extended pleurectomy/decortication — S. Bölükbas, M. Eberlein, et al. (2013)
• Lymphangitic carcinomatosis: A common radiographic manifestation of local failure following extended pleurectomy/decortication in patients with malignant pleural mesothelioma — I. Berger, K.A. Cengel, et al. (2019)

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