Three decades of experience in the surgical multi-modality management of pleural mesothelioma

Our plain-English summary of Three decades of experience in the surgical multi-modality management of pleural mesothelioma, by H. Luckraz, M. Rahman, N. Patel, et al (European Journal of Cardio-thoracic Surgery, 2010).

The study

• Authors: H. Luckraz, M. Rahman, N. Patel, A. Szafranek, A.R. Gibbs, E.G. Butchart
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2010;37(3):552-6
• Cited by: 52 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Optimal management of diffuse malignant pleural mesothelioma (DMPM) remains unclear. We report our 30-year surgical experience with DMPM with emphasis on surgical procedure and post-operative adjuvant therapy.

Methods: During the period of the study, 217 patients with DMPM were referred for surgical opinion. Patients who only had pleural biopsies were excluded (n=78). Consecutive patients who underwent surgical treatment were included (n=139). Surgical options were extra-pleural pneumonectomy (EPP) for Butchart stage I disease in clinically fit patients (n=49) or pleurectomy/decortication in patients who were either not fit for EPP or had advanced disease (Butchart stage II and III) or both (n=90). Post-operative adjuvant therapy included either chemotherapy, radiotherapy, both or none.

Results: The median follow-up was 10.0 months. The longest survival (median 26.0 months, IQR: 11.14-40.9 months) occurred in the pleurectomy/decortication group who received both post-operative chemotherapy and radiotherapy (n=24) (p<0.001). EPP whether or not combined with adjuvant therapy provided no significant survival advantage in comparison to pleurectomy/decortication (overall median survival 10.3 months vs 10.1 months, p=0.09). On univariate analysis, pleurectomy/decortication combined with chemotherapy and radiotherapy was the strongest predictor of prolonged survival (Hazard Ratio=3.6). Multivariate analysis with the inclusion of histological type, surgical procedure and type of adjuvant therapy, EPP without adjuvant therapy was an independent risk-factor for decreased survival (Hazard Ratio=9.2).

Conclusions: In this series, cytoreductive surgery combined with post-operative adjuvant therapy provided better survival despite either advanced disease or surgically less fit patients. Thus, pleurectomy/decortication may be the procedure of choice, given that neither surgical procedure (EPP or PD) is not curative.

Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

In plain English

This retrospective review covered surgical patients with diffuse malignant pleural mesothelioma at the authors' UK unit over about 30 years. Of 217 patients referred, 78 who had only a biopsy were excluded, leaving 139. Ninety had pleurectomy/decortication, removing the pleura and as much tumour as possible while keeping the lung. Forty-nine had extra-pleural pneumonectomy, removing the lung, pleura, diaphragm on that side and pericardium. Fit patients apparently with stage I disease were chosen for pneumonectomy. Afterwards, patients had chemotherapy, radiotherapy, both, or neither. Asbestos exposure was not reported. Thirty-day deaths were 1.1% after pleurectomy/decortication and 8.2% after pneumonectomy. The 24 patients given pleurectomy/decortication plus chemotherapy and radiotherapy lived longest: median 26.0 months, with a 95% confidence interval printed as 11.14 to 40.9 months in the text but 11.9 to 40.9 in a table. Pneumonectomy alone (12 patients) gave a median of 3.3 months (95% confidence interval 2.0 to 4.7). Pleurectomy/decortication patients tended to outlive pneumonectomy patients, a difference that was not statistically significant (p = 0.09). The authors concluded pneumonectomy may have only a limited role, as neither operation is curative.

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 consecutive surgical patients at a single unit (case series), with no randomisation
• Who was studied: 217 patients with diffuse malignant pleural mesothelioma referred for a surgical opinion at the authors' UK unit over about 30 years. 78 who had only a pleural biopsy were excluded, leaving 139: 90 had pleurectomy/decortication and 49 had extra-pleural pneumonectomy. Mean age was 58.9 years and 87% were male.
• Exposure: The article does not report asbestos or any other exposure. What it compares is treatment: pleurectomy/decortication or extra-pleural pneumonectomy, each followed by chemotherapy, radiotherapy, both, or neither.
• Main results:
  • 30-day mortality was 1.1% in the pleurectomy/decortication group and 8.2% in the extra-pleural pneumonectomy group (p = 0.03).
  • Among the 49 extra-pleural pneumonectomy patients, 8 (16%) had immediate post-operative infections and 7 (14%) developed broncho-pleural fistula after discharge.
  • The longest survival was in the 24 patients who had pleurectomy/decortication followed by both chemotherapy and radiotherapy: median 26.0 months. The Results text gives the 95% CI as 11.14 to 40.9 months, while Table 2 gives 11.9 to 40.9 months.
  • The 12 patients who had extra-pleural pneumonectomy alone had a median survival of 3.3 months (95% CI 2.0 to 4.7).
  • Pleurectomy/decortication patients as a whole tended to live longer than extra-pleural pneumonectomy patients, but this was not statistically significant (p = 0.09).
  • Patients with the epithelial type of mesothelioma survived longer (p = 0.002). Butchart stage did not influence long-term survival (p = 0.78).
  • On univariate analysis, pleurectomy/decortication plus chemotherapy and radiotherapy was the strongest predictor of prolonged survival (hazard ratio 3.6, no confidence interval given).
  • On multivariate analysis, extra-pleural pneumonectomy without adjuvant therapy was an independent risk factor for decreased survival (hazard ratio 9.2, no confidence interval given).
• The authors' conclusion: The authors concluded that, based on their results and those of others, extra-pleural pneumonectomy may have only a limited role in this disease, particularly as neither operation is curative. They said its place can only be settled by a randomised trial against pleurectomy/decortication in stage I disease.
• Limitations the authors state:
  • The study was retrospective and patients were not randomised to treatments.
  • The effect of tumour volume in stage I disease could not be analysed.
  • Chemotherapy and radiotherapy regimens changed over the study period, so the effects of specific regimens could not be assessed.
  • Many extra-pleural pneumonectomy patients were not well enough to receive adjuvant therapy, which the authors say influenced 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, Adjuvant Therapy, Pneumonectomy, Pleurectomy/Decortication (P/D), Chemotherapy, Median Survival, Hazard Ratio, Multivariate Analysis.

Related studies

• Clinical and pathological features of three-year survivors of malignant pleural mesothelioma following extrapleural pneumonectomy — D.J. Sugarbaker, A.S. Wolf, 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)
• Impact of induction therapy on postoperative outcome after extrapleural pneumonectomy for malignant pleural mesothelioma: does induction-accelerated hemithoracic radiation increase the surgical risk? — P. Mordant, K. McRae, et al. (2016)
• Induction chemotherapy, extrapleural pneumonectomy, and adjuvant radiotherapy for malignant pleural mesothelioma: experience of Guy's and St Thomas' hospitals — A. Bille, E. Belcher, et al. (2012)
• Three Decades of Malignant Pleural Mesothelioma: An Academic Center Experience — A. Nasser, A. Baird, et al. (2021)
• Pleuropneumonectomy in the management of diffuse malignant mesothelioma of the pleura. Experience with 29 patients — E.G. Butchart, T. Ashcroft, et al. (1976)

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