Video assisted thoracoscopic and open chest surgery in diagnosis and treatment of malignant pleural diseases

Our plain-English summary of Video assisted thoracoscopic and open chest surgery in diagnosis and treatment of malignant pleural diseases, by P. Perikleous, D.A. Waller (Journal of Visualized Surgery, 2017).

The study

• Authors: P. Perikleous, D.A. Waller
• Journal: Journal of Visualized Surgery
• Published: 2017;3:85
• Type of article: Review
• Cited by: 5 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Parenchymal cancers of lung, breast, gastrointestinal tract and ovaries as well as lymphomas and mesotheliomas are among the most common cancer types causing malignant effusions, though almost all tumour types have been reported to cause a malignant effusion. The prognosis heavily depends on patients' response to systemic therapy however, regardless of the causing pathology and histopathologic form, malignant pleural disease is normally associated with a poor prognosis. To date, there are not sufficient data to allow accurate predictions of survival that would facilitate decision making for managing patients with malignant pleural diseases. Interventions are directed towards drainage of the effusion and, when appropriate, concurrent or subsequent pleurodesis or establishing long-term drainage to prevent re-accumulation. The rate of re-accumulation of the pleural effusion, the patient's prognosis, and the severity of the patient's symptoms should guide the subsequent choice of therapy. In contemporary medicine, not many cancers have managed to generate as intense debates concerning treatment, as malignant pleural mesothelioma. The relative advantages of surgery, radiation, chemotherapy and any combination of the three are continuously reassessed and reconsidered, even though not always based on scientific evidence. The aim of surgery in mesothelioma may be prolongation of life, in addition to palliation of symptoms. Longer recovery periods from more extensive surgical procedures could be justified, in carefully selected patients. Surgical options include: Video assisted thoracoscopic (VATS) pleurodesis, VATS partial pleurectomy (VATS PP)-both parietal and visceral; open pleurectomy decortication (PD)-with an extended option (EPD) and extrapleural pneumonectomy (EPP). Current evidence implies that EPD can be performed reliably in specialised centres with good results, both in terms of mortality and survival; however, no operation has yet been shown to be beneficial in a prospective randomized controlled clinical trial.

In plain English

This narrative review came from the thoracic surgery department at Glenfield Hospital, Leicester, UK. It covered diagnosis and treatment of malignant pleural disease (cancer in the lining around the lung) by keyhole video-assisted thoracoscopic surgery (VATS) or open chest surgery. It discussed effusions from several cancers, with most attention on malignant pleural mesothelioma. Citing Cancer Research UK, it stated that asbestos has been linked with approximately 94% of UK mesothelioma cases. In the MesoVATS trial, one-year survival was 52% after VATS partial pleurectomy and 57% after talc pleurodesis. The MARS feasibility study concluded that extrapleural pneumonectomy within trimodal therapy offered no benefit and possibly harmed patients; the review said this was heavily criticised, as the study was not designed to test benefit. The review cited evidence that extended pleurectomy decortication, which spares the lung, is associated with 2½-fold lower short-term mortality than extrapleural pneumonectomy, noting that patient selection and treatment strategies differ between the operations. The authors concluded that extended pleurectomy decortication can be performed reliably in specialised centres, but that no operation has been shown beneficial in a prospective randomized controlled trial.

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 on thoracic surgery (no new patient data collected)
• Who was studied: Patients with malignant pleural diseases as described in published literature: effusions from lung, breast and other cancers, lymphoma, myeloma and leukaemia, and malignant pleural mesothelioma. The authors are from the thoracic surgery department at Glenfield Hospital, Leicester, UK.
• Exposure: The review studied surgical treatments, not asbestos exposure. Citing Cancer Research UK, it stated that asbestos has been linked with about 94% of UK mesothelioma cases. A figure taken from another review lists occupational, para-occupational and environmental asbestos exposure groups.
• Main results:
  • Reported from the MesoVATS trial (another study): overall survival at 1 year was 52% in the VATS partial pleurectomy group and 57% in the talc pleurodesis group.
  • Reported from the MARS feasibility study (another study): it concluded that extrapleural pneumonectomy within trimodal therapy offers no benefit and possibly harms patients.
  • The review noted that the MARS results were heavily criticised, partly because the conclusion was based on only 30 deaths. It stressed that MARS was a feasibility study, not designed to test whether EPP benefits patients.
  • Reported from a Glenfield Hospital study by Sharkey et al. (another study), covering 279 surgical patients: 65 had VATS partial pleurectomy and 214 had extended pleurectomy decortication. Among low-risk patients with epithelioid histology and performance status 0, survival was 17.4 months after extended pleurectomy decortication versus 10 months after VATS partial pleurectomy (P=0.017).
  • Citing other work, the review stated that extended pleurectomy decortication is associated with a 2½-fold lower short-term mortality than extrapleural pneumonectomy. It cautioned that patient selection and treatment strategies differ between the two operations.
  • Citing Cancer Research UK, the review stated that 2,700 new mesothelioma cases were diagnosed in the UK in 2014.
• The authors' conclusion: The authors concluded that current evidence implies (extended) pleurectomy decortication can be performed reliably in specialised centres with good results for mortality and survival. They added that no operation has been shown to be beneficial in a prospective randomized controlled clinical trial.
• Limitations the authors state:
  • The authors note a limitation of the evidence they reviewed: there are not enough data to accurately predict survival in malignant pleural diseases.

Topics

Medical terms in this study, explained in our Lexicon: Mesothelioma, Prognosis, Systemic Therapy, Pathology, Pleurodesis, Pleural Effusion, Pleural Mesothelioma, Chemotherapy.

Related studies

• Value of autofluorescence in video-assisted thoracoscopic surgery in pleural diseases — S.T. Liman, A. Elicora, et al. (2013)
• Should all patients who have mesothelioma diagnosed by video-assisted thoracoscopic surgery have their intervention sites irradiated? — M. Nagendran, A. Pallis, et al. (2011)
• The MesoVATS trial: is there a future for video-assisted thoracoscopic surgery partial pleurectomy? — R.C. Rintoul (2015)
• MesoTRAP: a feasibility study that includes a pilot clinical trial comparing video-assisted thoracoscopic partial pleurectomy decortication with indwelling pleural catheter in patients with trapped lung due to malignant pleural mesothelioma designed to address recruitment and randomisation uncertainties and sample size requirements for a phase III trial — C. Matthews, C. Freeman, et al. (2019)
• Comparison of video-assisted pleurectomy/decortication surgery plus hyperthermic intrathoracic chemotherapy with VATS talc pleurodesis for the treatment of malignant pleural mesothelioma: A pilot study — M. Migliore, M. Fiore, et al. (2023)
• Life expectancy of patients with malignant pleural effusion treated with video-assisted thoracoscopic talc pleurodesis — T. Laisaar, V. Palmiste, et al. (2006)

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