Surgery in Malignant Pleural Mesothelioma

Our plain-English summary of Surgery in Malignant Pleural Mesothelioma, by R. Bueno, I. Opitz, IASLC Mesothelioma Taskforce (Journal of Thoracic Oncology, 2018).

The study

• Authors: R. Bueno, I. Opitz, IASLC Mesothelioma Taskforce
• Journal: Journal of Thoracic Oncology
• Published: 2018;13(11):1638-1654
• Type of article: Review
• Cited by: 71 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Surgical intervention plays an important role in the diagnosis, staging, and treatment of malignant pleural mesothelioma (MPM) and can be applied with curative or palliative intent. The overall aim of surgery should be, as in any oncologic surgery, the macroscopic complete resection (MCR) of the tumor. Most importantly, the majority of patients with the diagnosis of MPM should be appropriately staged and initially evaluated in a multidisciplinary setting, including medical oncology, radiation oncology, and surgery after histologic diagnosis. Surgical staging, including determination of the histologic subtype and lymph node status, as well as clinical staging with positron-emission tomography-computer tomography scan and determination of cardiopulmonary reserve are crucial. Herein, we summarize the role of surgical resection, specifically macroscopic complete resection, performed as extrapleural pneumonectomy or extended pleurectomy/decortication in multimodality treatment settings and advocate for optimal patient selection for one or the other procedure. In addition, the roles of surgery in diagnosis of MPM and in palliative care are discussed.

Copyright © 2018 International Association for the Study of Lung Cancer. All rights reserved.

In plain English

This is a review article by two thoracic surgeons, written on behalf of the IASLC Mesothelioma Taskforce. It summarized earlier published work on surgery for malignant pleural mesothelioma. It also briefly mentioned an unpublished quality-of-life analysis of the authors' own patients. It covered surgical biopsy for diagnosis, extrapleural pneumonectomy (removal of the pleura and lung, usually with the diaphragm and pericardium), and pleurectomy/decortication (removal of the pleura while sparing the lung, sometimes with the diaphragm and pericardium). It also covered palliative surgery and surgery for recurrence. The review cited a meta-analysis in which short-term deaths were significantly more common after extrapleural pneumonectomy (4.5%) than after pleurectomy/decortication (1.7%). That meta-analysis found no significant difference in 2-year mortality. It cited database data showing more postoperative lung failure (ARDS) at centers doing fewer than five extrapleural pneumonectomies a year. The authors said the studies differed widely, which made the two operations hard to compare. The authors concluded that surgery has a role at all stages of the disease, and that the field has moved toward pleurectomy/decortication. 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: narrative review article
• Who was studied: Published studies, trials, guidelines and database analyses on surgery for malignant pleural mesothelioma, plus a brief mention of an unpublished quality-of-life analysis of the authors' own patients who had induction chemotherapy over a 2-year period
• Main results:
  • In a cited meta-analysis (1,512 patients receiving pleurectomy/decortication and 1,391 receiving extrapleural pneumonectomy), short-term mortality was significantly higher in the extrapleural pneumonectomy group (4.5%) than in the pleurectomy/decortication group (1.7%)
  • In the same meta-analysis, 2-year mortality did not differ significantly between the groups (23.8% versus 25%), but the included studies were significantly heterogeneous
  • Of 17 studies in the meta-analysis that reported median survival, 53% reported longer median survival with extrapleural pneumonectomy and 47% with pleurectomy/decortication
  • In a cited Society of Thoracic Surgeons database analysis, postoperative ARDS after extrapleural pneumonectomy occurred in 0 of 31 patients at centers doing five or more per year and in 8 of 64 (12.5%) at centers doing fewer than five per year
  • In the authors' own unpublished analysis, patients filled out quality-of-life questionnaires before surgery and at 6 weeks and 4 months after. After both procedures, some measures, such as general health score, vitality, social functioning and mental health, were better at 4 months than before the operation
  • The authors noted that in the MARS I trial, which concluded that extrapleural pneumonectomy offered no benefit, only 16 of 24 patients assigned to that arm received radical surgery. They said the trial was designed to test feasibility, not benefit
  • In the cited MesoVATS trial, survival was about the same, but VATS pleurectomy improved control of recurrent fluid build-up compared with talc pleurodesis
  • In a cited series of 47 patients who had chest wall resection for recurrence, median survival after the resection was 20.4 months in patients with the epithelioid subtype and 7.4 months in patients with the biphasic subtype
• The authors' conclusion: The authors concluded that surgery has a role in managing malignant pleural mesothelioma at all stages, that surgeons should be involved in multimodality care, and that in the past decade the focus has moved toward pleurectomy/decortication as definitive treatment
• Limitations the authors state:
  • The authors said the published reports used different patient selection, treatment protocols, definitions of morbidity and ways of calculating survival. This made it hard to judge which operation is better
  • The authors said there are few data on quality of life after these operations
  • The authors said the literature on surgery for recurrence is scarce

Topics

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

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Staging, Palliative Care, Histological Subtype, Surgical Resection, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D).

Related studies

• Divided by an ocean of water but united in an ocean of uncertainty: A transatlantic review of mesothelioma surgery guidelines — D.A. Waller, I. Opitz, et al. (2021)
• Phase III randomized trial of surgery with or without intraoperative photodynamic therapy and postoperative immunochemotherapy for malignant pleural mesothelioma — H.I. Pass, B.K. Temeck, et al. (1997)
• Treatment factors associated with long-term survival after cytoreductive surgery and regional chemotherapy for patients with malignant peritoneal mesothelioma — H.R. Alexander, D.L. Bartlett, et al. (2013)
• Outcomes of repeat cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for the treatment of peritoneal surface malignancy — K.I. Votanopoulos, C. Ihemelandu, et al. (2012)
• Complete cytoreductive surgery plus HIPEC for peritoneal metastases from unusual cancer sites of origin: results from a worldwide analysis issue of the Peritoneal Surface Oncology Group International (PSOGI) — D. Goéré, G. Passot, et al. (2017)
• Pretreatment serum C-reactive protein levels predict benefit from multimodality treatment including radical surgery in malignant pleural mesothelioma: a retrospective multicenter analysis — B. Ghanim, M.A. Hoda, et al. (2012)

Browse more research in Journal of Thoracic Oncology, or return to medical research.