Summary of prognostic factors and patient selection for extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma

Our plain-English summary of Summary of prognostic factors and patient selection for extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma, by C. Cao, T.D. Yan, P.G. Bannon, et al (Annals of Surgical Oncology, 2011).

The study

• Authors: C. Cao, T.D. Yan, P.G. Bannon, B.C. McCaughan
• Journal: Annals of Surgical Oncology
• Published: 2011;18(10):2973-9
• Type of article: Systematic review
• Cited by: 28 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Extrapleural pneumonectomy (EPP) has been shown to improve long-term survival outcomes in selected patients with malignant pleural mesothelioma (MPM). The present study aimed to evaluate potential prognostic factors on overall survival for patients who underwent EPP for MPM and to examine the patient selection process in major referral centers that perform EPP.

Methods: A systematic review of the current literature was performed using 5 electronic databases. Relevant studies with prognostic data on overall survival for patients with MPM treated by EPP were included for review. Two reviewers independently assessed each included study.

Results: A total of 17 studies from 13 institutions containing the most updated and complete data on prognostic factors for patients with MPM who underwent EPP were included for review. A number of quantitative, clinical, and treatment-related factors were identified to have significant impact on overall survival.

Conclusions: Patients with nonepithelial MPM and nodal involvement have consistently demonstrated to have a worse prognosis after EPP. Their eligibility as candidates for EPP should be questioned. The preoperative patient selection process currently differs greatly between institutions and should focus on identifying patients with nonepithelial histologic subtypes and nodal involvement to exclude them as EPP surgical candidates in the future.

In plain English

This article was a systematic review, not a new study of patients. The authors searched five medical databases for articles from January 1985 to September 2010 on extrapleural pneumonectomy (EPP). EPP is an operation that removes the chest lining, the lung and the diaphragm on one side, and it was used here in people with malignant pleural mesothelioma. The authors included 17 studies from 13 centers that reported factors linked to overall survival. Eleven of 17 studies found the tumor's cell type (histological subtype) to be a significant prognostic factor. Eleven of the 14 studies that looked at lymph node involvement found it significant. In the authors' summary table, asbestos exposure was listed as significant in one study and not significant in three. The authors also found that the way patients were selected for surgery differed greatly between centers. They concluded that patients with nonepithelial mesothelioma and nodal involvement consistently had a worse prognosis after EPP, and that their eligibility for the operation should be questioned. They noted that no randomized trial had been completed and that most studies were retrospective, so selection bias could not be ruled out.

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: systematic review of published studies (no pooled statistical analysis)
• Who was studied: 17 studies from 13 centers on patients with histologically proven malignant pleural mesothelioma treated with EPP. Articles were searched from January 1985 to September 2010. Studies with 20 or fewer patients were excluded.
• Exposure: The treatment studied was extrapleural pneumonectomy, alone or as part of multimodality therapy. Asbestos exposure appeared only as one of the prognostic factors tabulated.
• Main results:
  • Median overall survival for selected subgroups across the reviewed studies ranged from 9 to 35 months.
  • 11 of 17 studies found histological subtype to be a significant prognostic factor, 4 of them on multivariate analysis.
  • Of 14 studies reporting on nodal staging, all but 3 found a prognostic significance; 7 found nodal involvement significantly harmful on multivariate analysis.
  • Of 11 studies reporting on disease stage, 7 found a statistical significance.
  • Complete cytoreduction (complete removal of tumor) was associated with improved survival in 3 of 5 studies that reported on it.
  • In the summary table, asbestos exposure was a significant factor (on multivariate analysis) in 1 study and not significant in 3 studies.
  • The process for selecting patients for EPP differed greatly between major institutions and over time.
• The authors' conclusion: The authors concluded that patients with nonepithelial MPM and nodal involvement consistently had a worse prognosis after EPP, and that their eligibility for EPP should be questioned. They also concluded that preoperative selection should focus on identifying such patients in order to exclude them.
• Limitations the authors state:
  • No pooled statistical analysis (forest plot) was done because randomized and comparative studies were lacking.
  • Most reviewed studies were retrospective, so selection bias cannot be ruled out.
  • No completed randomized controlled trial of EPP existed.
  • Survival was measured from different starting points in different studies.
  • Comparisons between disease stages were arbitrarily assigned across studies.
  • Age was difficult to assess because age limits for patient selection varied between institutions.

Topics

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

Medical terms in this study, explained in our Lexicon: Extrapleural Pneumonectomy (EPP), Pleural Mesothelioma, Overall Survival, Systematic Review, Prognosis, Histological Subtype.

Related studies

• Extrapleural pneumonectomy for malignant pleural mesothelioma: outcomes of treatment and prognostic factors — T.D. Yan, M. Boyer, et al. (2009)
• Low calretinin expression and high neutrophil-to-lymphocyte ratio are poor prognostic factors in patients with malignant mesothelioma undergoing extrapleural pneumonectomy — S.C. Kao, S. Klebe, et al. (2011)
• Extrapleural pneumonectomy in the treatment of epithelioid malignant pleural mesothelioma: novel prognostic implications of combined N1 and N2 nodal involvement based on experience in 529 patients — D.J. Sugarbaker, W.G. Richards, et al. (2014)
• Staging of patients after extrapleural pneumonectomy for malignant pleural mesothelioma--institutional review and current update — C. Cao, S.K. Krog Andvik, et al. (2011)
• 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)
• Extrapleural pneumonectomy or supportive care: treatment of malignant pleural mesothelioma? — S. Sharif, I. Zahid, et al. (2011)

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