The Prevalence and Clinical Relevance of Nonexpandable Lung in Malignant Pleural Mesothelioma. A Prospective, Single-Center Cohort Study of 229 Patients

Our plain-English summary of The Prevalence and Clinical Relevance of Nonexpandable Lung in Malignant Pleural Mesothelioma. A Prospective, Single-Center Cohort Study of 229 Patients, by A.C. Bibby, P. Halford, D. De Fonseka, et al (Annals of the American Thoracic Society, 2019).

The study

• Authors: A.C. Bibby, P. Halford, D. De Fonseka, A.J. Morley, S. Smith, N.A. Maskell
• Journal: Annals of the American Thoracic Society
• Published: 2019;16(10):1273-1279
• Cited by: 27 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Rationale: Nonexpandable lung is a recognized phenomenon that can create management challenges in patients with mesothelioma. Its prevalence and clinical importance are unknown.Objectives: The aim of this study was to describe the prevalence of nonexpandable lung and to evaluate whether there was any association between nonexpandable lung and survival in a clinical cohort of patients with mesothelioma.Methods: This was a prospective, observational cohort study of patients with mesothelioma who were seen in a single center between March 1, 2008, and August 3, 2017. Baseline characteristics were collected at diagnosis. Serial chest radiographs were assessed for the presence of pleural effusions and nonexpandable lung (defined as a lack of lung expansion after pleural aspiration or drainage). Patients were followed until they died or were censored on March 14, 2019.Results: Of 229 patients, 192 (82.7%) had a pleural effusion at presentation, and nonexpandable lung was observed in 64 of these 192 patients (33.3%). Breathlessness and cough were more frequent in patients with pleural effusions, especially in those with underlying nonexpandable lung, whereas chest pain was more prevalent in patients without effusions. Patients with pleural effusions, both with and without underlying nonexpandable lung, were more likely to have epithelioid or early-stage disease and to receive chemotherapy than patients with no pleural effusion. Nonexpandable lung was an independent risk factor for short survival, with a hazard ratio for mortality of 1.80 (95% confidence interval, 1.16-2.80) compared with patients without nonexpandable lung. The presence of a pleural effusion did not appear to be associated with a worse prognosis compared with patients with an effusion (adjusted hazard ratio, 1.86; 95% confidence interval, 0.93-3.72).Conclusions: This is the first study to describe the prevalence and clinical implications of nonexpandable lung in mesothelioma. It demonstrates that nonexpandable lung is a relatively common phenomenon that is associated with significant symptomatology and shorter survival.Keywords: mesothelioma; nonexpandable lung; pleural effusion.

In plain English

This prospective study followed 229 patients with malignant pleural mesothelioma seen at one center in the United Kingdom between March 2008 and August 2017. It looked at nonexpandable lung, meaning the lung did not fully re-expand on chest X-ray after fluid around it was drained. The study did not examine asbestos exposure. Of the 229 patients, 192 (83.8%) had fluid around the lung (a pleural effusion) when they first came to the center, and 64 of these 192 (33.3%) had nonexpandable lung. Breathlessness and cough were most common in patients with nonexpandable lung. Chest pain was most common in patients without effusions. An unadjusted analysis showed no convincing link between nonexpandable lung and death. After adjustment for other factors, nonexpandable lung was linked to a higher risk of death (hazard ratio 1.80, 95% confidence interval 1.16 to 2.80) compared with its absence. Having an effusion was not itself associated with survival. The authors concluded that nonexpandable lung was an independent predictor of poor survival. They noted that the subgroup was small and that some cases may have been missed.

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: Prospective, single-center observational cohort study
• Who was studied: 229 patients with malignant pleural mesothelioma (196 male) enrolled at a single center in the United Kingdom between March 1, 2008, and August 3, 2017, as part of a pleural investigation study
• Exposure: Not asbestos exposure. The factor studied was nonexpandable lung (failure of the lung to re-expand on chest radiograph after pleural fluid removal). Patients were grouped as no pleural effusion (37), effusion without nonexpandable lung (128), or effusion with nonexpandable lung (64).
• Main results:
  • 192 of 229 patients (83.8%) had a pleural effusion at presentation
  • 64 of the 192 patients with pleural effusions (33.3%) had nonexpandable lung
  • Breathlessness was reported by 90.6% of patients with nonexpandable lung, 82% of patients with effusions but no nonexpandable lung, and 54.1% of patients without effusions
  • Cough followed the same pattern: 51.6% with nonexpandable lung, 37.5% with effusion but no nonexpandable lung, and 21.6% without effusion
  • Chest pain was reported by 64.9% of patients without effusions, 42.2% of patients with effusions but no nonexpandable lung, and 34.4% of patients with nonexpandable lung
  • In the unadjusted analysis there was no convincing association between nonexpandable lung and mortality (crude hazard ratio 1.02, 95% CI 0.67 to 1.56, per Table 2)
  • In the adjusted model, nonexpandable lung was associated with an increased risk of death compared with the absence of nonexpandable lung (hazard ratio 1.80; 95% confidence interval 1.16 to 2.80)
  • Having a pleural effusion was not associated with survival: unadjusted hazard ratio 1.02 (95% CI 0.70 to 1.46), adjusted hazard ratio 1.86 (95% CI 0.93 to 3.72)
  • Across the whole cohort, chest pain was associated with shorter survival (hazard ratio 1.89; 95% CI 1.26 to 2.83). Other symptoms were not markers of poor prognosis.
  • Among the 64 patients with nonexpandable lung, the degree of nonexpandable lung was not associated with survival (hazard ratio 0.85; 95% CI 0.66 to 1.10; P = 0.213)
  • Of the 64 patients with nonexpandable lung, 31 (48.4%) were managed with an indwelling pleural catheter. In 18 of the 64 (28.1%), disease progression later closed the pleural space (autopleurodesis).
  • Median survival for the whole cohort was 11.1 months, and 15 patients (6.6%) were alive at the time of analysis
• The authors' conclusion: The authors concluded that nonexpandable lung affected one-third of patients with mesothelioma and effusions, was associated with breathlessness and cough, and was an independent predictor of poor survival after adjustment for tumor stage, presence of effusion, and treatment received
• Limitations the authors state:
  • The subgroup of patients with nonexpandable lung was small, so the analysis of its degree may have missed a real relationship
  • There is no validated system for measuring the size of nonexpandable lung, so a scoring system designed for pleural effusions was used
  • Chest radiographs were used, and computed tomography may be more sensitive for detecting nonexpandable lung
  • Imaging followed routine clinical practice rather than a set schedule, so some cases may have been missed, which would underestimate prevalence
  • The study could not measure symptom severity or track how symptoms changed over time

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: Trapped Lung, Pleural Mesothelioma, Cohort Study, Mesothelioma, Chest X-Ray, Pleural Effusion, Epithelioid, Chemotherapy.

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