Extended Pleurectomy/Decortication for Malignant Pleural Mesothelioma: Humanitas's Experience

Our plain-English summary of Extended Pleurectomy/Decortication for Malignant Pleural Mesothelioma: Humanitas's Experience, by G. Mangiameli, E. Bottoni, E. Voulaz, et al (Journal of Clinical Medicine, 2021).

The study

• Authors: G. Mangiameli, E. Bottoni, E. Voulaz, U. Cariboni, A. Testori, A. Crepaldi, V.M. Giudici, E. Morenghi, M. Alloisio
• Journal: Journal of Clinical Medicine
• Published: 2021;10(21)
• Cited by: 7 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: We analysed a series of malignant pleural mesothelioma (MPM) patients who consecutively underwent extended Pleurectomy/Decortication (eP/D) in a centre with a high level of thoracic surgery experience (IRCCS Humanitas Research Hospital) to explore postoperative morbidity and mortality, pattern of recurrence and survival.

Methods: A retrospective analysis was performed on MPM patients underwent eP/D in our centre from 2010 to 2021. All patients were identified from our departmental database. Postoperative complications were scored according to Clavien-Dindo criteria. Survival analysis was performed by the Kaplan-Meier methods and Cox multivariable analysis.

Results: Eighty-five patients underwent extended pleurectomy decortication (eP/D) during study period. Macroscopical residual disease (R2) was reported in one case. A neoadjuvant chemotherapy regiment was administrated in 88% of the surgical cohort. A complete trimodality treatment including induction with platinum agents and pemetrexed, radical cytoreductive surgery and volumetric modulated arc therapy technology (VMAT) could be administered in 63 patients (74%). Postoperative morbidity rate was 54.11%, major complications (defined as Clavien-Dindo ≥ 3) were reported in 11 patients (12.9%). Thirty-day mortality and 90-day mortality were, respectively, 2.35% and 3.53%. Median disease-free and overall survival were, respectively, 13.7 and 25.5 months. The occurrence of major complications (Clavien-Dindo ≥ 3), operative time, pT3-T4, pathological node involvement (pN+) were prognostic factors associated with worse survival.

Conclusions: In our experience, eP/D is a well-tolerated procedure with acceptable mortality and morbidity, allowing for the administration of trimodality regimens in most patients. eP/D offered in a multimodality treatment setting have satisfactory long term oncological results. To obtain best oncological results the goal of surgery should be macroscopic complete resection in carefully selected patients (clinical N0).

In plain English

This retrospective review covered 85 malignant pleural mesothelioma patients who had extended pleurectomy/decortication in Milan, Italy, from 2010 to April 2021. The operation removes the lung's lining but keeps the lung. Asbestos exposure was recorded in 75 patients; no fiber types or jobs are given. Most had chemotherapy before surgery; 63 (74%) completed chemotherapy, surgery and radiotherapy. Complications occurred in 46 patients (54%) and were major in 11 (12.9%). Deaths within 30 and 90 days were 2.35% and 3.53%. Median disease-free and overall survival were 13.7 and 25.5 months. The figures given with them (9.01 to 31.71 and 15.07 to 47.5) are called 95% confidence intervals in the text but interquartile ranges in a table. After adjustment, major complications, longer operations and lymph-node cancer were linked to shorter overall survival. Recorded asbestos exposure was not statistically significantly associated with survival. The authors concluded the operation was well tolerated and let most patients complete all three treatments. They also said surgery should aim to remove all visible tumor in carefully selected patients without clinically detected lymph-node involvement (clinical N0). They named the retrospective design as the main limitation.

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 single-centre review of consecutive patients treated surgically (surgical case series)
• Who was studied: 85 patients aged 18 or older with malignant pleural mesothelioma who underwent extended pleurectomy/decortication with radical intent at Humanitas Research Hospital, Milan, Italy, from 2010 to April 2021. 62 were male (72.94%), mean age was 65.2, and 75 had epithelioid histology.
• Exposure: The treatment studied was extended pleurectomy/decortication, mostly combined with platinum and pemetrexed chemotherapy beforehand and VMAT radiotherapy afterwards. Asbestos exposure was recorded only as present or absent: it was present in 75 of the 85 patients (88.23%). No fiber types, products, jobs or doses are given.
• Main results:
  • Only one of the 85 operations left visible tumor behind, because of invasion of the superior vena cava.
  • 63 of 85 patients (74%) received the complete trimodality treatment: induction chemotherapy, surgery and VMAT radiotherapy.
  • Complications after surgery occurred in 46 of 85 patients (54%). They were grade 3 or higher in 11 patients (12.9%). Empyema was the most common major complication (5 of 11).
  • 30-day mortality was 2.35% and 90-day mortality was 3.53% (2 and 3 of 85 patients, per Table 1).
  • Median disease-free survival was 13.7 months (9.01–31.71) and median overall survival was 25.5 months (15.07–47.5) for the 85 patients. The text labels these intervals as 95% CIs, but Table 2 labels the same figures as IQR.
  • The estimated 5-year overall survival probability was 19.64%.
  • Of 56 patients whose disease came back, 11 (19.6%) had local recurrence, 4 (7.1%) had distant recurrence and 35 (62.5%) had both.
  • Of all patients, 39 (45.88%) died of mesothelioma recurrence or progression by the end of follow-up.
  • In multivariable analysis, three factors remained significantly associated with worse overall survival: major complications (HR 2.80, 95% CI 1.20–6.53), operation time per hour (HR 1.40, 95% CI 1.07–1.84) and lymph node involvement pN+ (HR 2.74, 95% CI 1.49–5.06).
  • In multivariable analysis, two factors remained significantly associated with worse disease-free survival: operation time (HR 1.36, 95% CI 1.10–1.68) and pN+ (HR 2.58, 95% CI 1.47–4.53).
  • Recorded asbestos exposure was not statistically significantly associated with disease-free survival (HR 0.79, 95% CI 0.34–1.87, p 0.594) or with overall survival (HR 0.83, 95% CI 0.29–2.36, p 0.730) in univariable analysis.
  • After VMAT radiotherapy, one case of grade 2 radiation pneumonia was seen and no grade 3 or higher complications.
• The authors' conclusion: The authors concluded that extended pleurectomy/decortication is well tolerated, with slightly reduced mortality and morbidity, and allows most patients to receive trimodality treatment. They also concluded that it gives satisfactory long-term results in a multimodality setting, and that surgery should aim for removal of all visible tumor in carefully selected patients (clinical N0).
• Limitations the authors state:
  • The main limitation was the retrospective design.

Topics

Medical terms in this study, explained in our Lexicon: Pleurectomy/Decortication (P/D), Pleural Mesothelioma, Thoracic Surgery, Neoadjuvant Therapy, Pemetrexed (Alimta), Cytoreductive Surgery, Overall Survival.

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