Second surgery for recurrence of malignant pleural mesothelioma after extrapleural pneumonectomy

Our plain-English summary of Second surgery for recurrence of malignant pleural mesothelioma after extrapleural pneumonectomy, by L. Politi, G. Borzellino (The Annals of Thoracic Surgery, 2010).

The study

• Authors: L. Politi, G. Borzellino
• Journal: The Annals of Thoracic Surgery
• Published: 2010;89(1):207-10
• Cited by: 24 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Extrapleural pneumonectomy is a treatment option for malignant pleural mesothelioma (MPM), but disease recurrence is common. Among different therapeutic options for recurrence, we have found no reports for second surgical procedures.

Methods: We retrospectively evaluated the types and outcomes of surgical management of solid recurrences of MPM, in a series of 74 patients treated with extrapleural pneumonectomy over a 20-year period.

Results: Of 57 patients for whom follow-up data were available, 11 patients experienced recurrent disease in the form of a solid mass, 1.5 to 12 years after the initial treatment; 8 of these patients had sufficiently good clinical conditions to undergo a second surgery with curative intent. Chest wall resection was performed in 4 cases of parietal recurrence, radical retroperitoneal resection was done in 3 cases of retroperitoneal relapse, and segmental resection of the remaining lung was done in one case of pulmonary metastasis. In this latter case, although computed tomographic images showed a solid mass, at surgery the disease was found to have a serosal nature, precluding the possibility of a curative surgery. Median survival after the second surgery was 14.5 months (range, 6 to 29); no association between survival and site of recurrence, age or disease-free interval was found.

Conclusions: In this series, the second surgery did not offer the expected survival benefit of curative treatment strategies and should therefore be considered palliative. Second surgery may be a treatment option in a subset of patients who experience a solid recurrence of MPM that is symptomatic or near vital organs and who cannot undergo additional radiotherapy.

2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

In plain English

This was a retrospective study from hospitals in Florence and Verona, Italy, of patients with malignant pleural mesothelioma whose cancer returned after extrapleural pneumonectomy. Of 74 patients with stage I or II disease treated this way over 20 years, 57 had follow-up data. In 42, the cancer returned within 18 months along the linings of the body cavities and could not be operated on. In 11, it returned as a solid mass. Eight of these 11 had a second operation intended to cure. There were no deaths or major complications. Surgery relieved chest pain in the 4 patients whose tumor had returned in the chest wall. In one patient, the disease found at surgery could not be cured. Median survival after the second surgery was 14.5 months (range 6 to 29). No association was found between survival and site of recurrence, age, or time free of disease. The authors concluded that the second surgery did not give the survival benefit expected of curative treatment and should be considered palliative. They noted the study was small and retrospective. The article does not discuss asbestos exposure.

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 medical records (case series) of patients given a second surgery for recurrent malignant pleural mesothelioma
• Who was studied: 74 patients with Butchart stage I or II malignant pleural mesothelioma treated with extrapleural pneumonectomy since 1988 at Careggi Hospital, Florence, and the University Hospital of Verona, Italy. 3 died after surgery and 14 were lost to follow-up, leaving 57. The 8 patients who had a second surgery for a solid recurrence (6 men and 2 women, mean age 53.6 years) were the subject of the study.
• Exposure: The article reports no asbestos exposure information. What was studied was a second operation, with curative intent, for a solid recurrence of mesothelioma after extrapleural pneumonectomy: chest wall resection, radical retroperitoneal resection, or wedge resection of the remaining lung.
• Main results:
  • Of 57 patients with follow-up data, 11 had a recurrence in the form of a solid mass.
  • In 42 of the 57 patients, the disease recurred along the serosal linings (peritoneal or pericardial cavities, or the opposite pleura) within 18 months, and no further surgery was possible for them.
  • Of the 11 patients with a solid recurrence, surgery was ruled out for the 3 oldest (aged 72 to 75). The remaining 8 were operated on.
  • Among the 8 operated patients, 4 had chest wall resection for recurrence in the chest wall and 3 had radical retroperitoneal resection. The eighth had a segmental resection of the remaining lung.
  • None of the 8 patients died from the second surgery and none had major complications. Mean hospital stay after surgery was 10 days (range 8 to 16 days).
  • Surgery relieved chest pain in the 4 patients whose recurrence was in the chest wall.
  • In the patient with a lung metastasis, the disease looked like a solid mass on CT, but at surgery it was found to have spread in the pleura, so the operation could not be curative.
  • In one patient with retroperitoneal recurrence 5 years after the first surgery, the cell type had changed from epithelial to sarcomatoid.
  • Median survival after the second surgery for the 8 patients was 14.5 months (range 6 to 29).
  • Among the 8 operated patients, no association was found between survival and site of recurrence, age, or disease-free interval.
  • No retroperitoneal recurrence was seen among the 24 patients who had a second minithoracotomy during their first operation. The authors suggested this procedure may have had a beneficial effect.
• The authors' conclusion: The authors concluded that, in this series, the second surgery did not give the survival benefit expected of curative treatment and should be considered palliative.
• Limitations the authors state:
  • The study was retrospective and covered a long period during which diagnosis and treatment changed.
  • The study was purely observational and did not compare second surgery with other treatments.
  • The small number of cases may have prevented the authors from finding factors significantly associated with survival.

Topics

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

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Extrapleural Pneumonectomy (EPP), Metastasis, Median Survival, Palliative Care.

Related studies

• Patterns of failure, toxicity, and survival after extrapleural pneumonectomy and hemithoracic intensity-modulated radiation therapy for malignant pleural mesothelioma — D.R. Gomez, D.S. Hong, et al. (2013)
• Invited commentary — D. Rice (2010)
• Intrathoracic chemo-thermotherapy with radiofrequency waves after extrapleural pneumonectomy for malignant pleural mesothelioma — T. Tokunaga, M. Higashiyama, et al. (2011)
• Early recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) — G.H.C. Tan, C.S. Chia, et al. (2018)
• Adjuvant radiotherapy after extrapleural pneumonectomy for mesothelioma. Prospective analysis of a multi-institutional series — S. Tonoli, P. Vitali, et al. (2011)
• Extrapleural pneumonectomy for early stage malignant pleural mesothelioma: a harmful procedure — O. Rena, C. Casadio (2012)

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