Extrapleural pneumonectomy for sarcoma: Outcomes of adult patients at a specialized center

Our plain-English summary of Extrapleural pneumonectomy for sarcoma: Outcomes of adult patients at a specialized center, by B.Y. Zhang, A.R. Wilson-Smith, E.A. Connolly, et al (Cancer Reports, 2024).

The study

• Authors: B.Y. Zhang, A.R. Wilson-Smith, E.A. Connolly, M.C. Strach, N. Ussher, T. Yan, V.A. Bhadri
• Journal: Cancer Reports
• Published: 2024;7(4):e2065
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Extrapleural pneumonectomy (EPP) is a complex surgical procedure involving en-bloc resection of the parietal and visceral pleura, lung, pericardium, and ipsilateral diaphragm. Small case series of pleural-based sarcoma of predominantly pediatric patients suggest EPP may be a life-prolonging surgical option. We aimed to describe the characteristics and outcomes of adults who underwent EPP at a specialized sarcoma center.

Methods: Clinicopathologic variables, surgical details, and follow-up information were extracted for patients undergoing EPP for pleural-based sarcoma between August 2017 and December 2020. Primary outcomes were event-free survival (EFS) and overall survival (OS) from the date of EPP. Secondary outcomes were disease-free interval (DFI) prior to EPP, and early and late postoperative complications.

Results: Eight patients were identified, seven with soft tissue sarcoma and one with bone sarcoma. Patients had either localized disease with a primary thoracic sarcoma, sarcoma recurrent to the thorax, or de novo metastatic disease. All patients underwent resection of their pleural-based sarcoma by an experienced cardiothoracic surgeon, and some patients had pre or postoperative treatment. The perioperative morbidity was comparable with previously published reports of EPP performed in mesothelioma patients. At median follow-up of 22.5 months, median EFS was 6.0 months and OS was 20.7 months. Six patients (75%) had disease recurrence; five (62.5%) died of progressive disease. Two patients (25%) had not recurred: one died of a radiation-related esophageal rupture, and one was alive with no evidence of disease at 37.0 months. Characteristics of those with the longest EFS included low-grade histology and achieving a metabolic response to preoperative chemotherapy.

Conclusions: In adults with pleural-based sarcoma, EPP is rarely curative but appears to be a feasible salvage procedure when performed at specialized centers. Patient selection is critical with strong consideration given to multimodal therapy to optimize patient outcomes. In the absence of a confirmed response to neoadjuvant treatment, long term survival is poor and EPP should not be recommended.

© 2024 The Authors. Cancer Reports published by Wiley Periodicals LLC.

In plain English

This article does not study asbestos. It is a small case series from a sarcoma unit in Sydney, Australia. The authors reviewed the records of eight adults, median age 41, who had extrapleural pneumonectomy (EPP) for pleural-based sarcoma between August 2017 and December 2020. EPP is an operation that removes the lung together with the pleura, pericardium and diaphragm on one side. Seven patients had soft tissue sarcoma and one had bone sarcoma. At a median follow-up of 22.5 months, median event-free survival after surgery was 6.0 months and median overall survival was 20.7 months. Six of the eight patients (75%) had their cancer return, and five (62.5%) died of their disease. No patient died within 30 days of surgery, and three had early complications. The authors concluded that EPP was not curative for most patients but can be done with acceptable surgical risk at specialized centers. They noted that the study was retrospective and small and included many tumor types.

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: Case series from a retrospective chart review
• Who was studied: Eight adults (median age 41, range 22 to 70) with pleural-based sarcoma who had EPP at the Chris O'Brien Lifehouse/Royal Prince Alfred Hospital sarcoma unit, Sydney, between August 2017 and December 2020. Seven had soft tissue sarcoma (three synovial sarcoma, plus one each of intimal sarcoma, malignant solitary fibrous tumor, rhabdomyosarcoma and undifferentiated pleomorphic sarcoma) and one had chondrosarcoma.
• Exposure: No asbestos, fiber or occupational exposure was studied. The study looked at outcomes of a surgical treatment, extrapleural pneumonectomy, given with or without chemotherapy or radiation before or after surgery.
• Main results:
  • Among the 8 patients, at a median follow-up of 22.5 months, median event-free survival after EPP was 6.0 months and median overall survival from EPP was 20.7 months.
  • Six of 8 patients (75%) had disease recurrence: four distant and two local.
  • Five of 8 patients (62.5%) died of disease-related causes.
  • One patient (chondrosarcoma) remained free of disease 37.0 months after EPP. Another patient with no recurrence died after 42.3 months of follow-up; the text gives the cause as chronic sepsis, and the table gives it as a radiation complication (esophageal perforation).
  • No patient died within 30 days of EPP. Three patients had early postoperative complications, and one patient had a severe late complication (group A streptococcal bacteremia).
  • Median operation time was 4 hours and median hospital stay was 14 days.
  • The four patients who did not recur or who went more than a year without an event had either low-intermediate grade tumors or a partial response to chemotherapy given before surgery. These are observations only, with no statistical testing.
• The authors' conclusion: The authors concluded that EPP did not cure most adults with pleural-based sarcoma, but that it can be performed with acceptable surgical risk by experienced teams at specialized centers. They suggested that patients considered for EPP first receive chemotherapy and show a confirmed response.
• Limitations the authors state:
  • The study was retrospective, the sample was small, and it included a variety of sarcoma subtypes.
  • The small numbers did not allow formal statistical analysis of which patient characteristics affected 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: Extrapleural Pneumonectomy (EPP), Sarcoma, Visceral Pleura, Pericardium, Diaphragm, Overall Survival, Thorax, De Novo.

Related studies

• Extra-Pleural Pneumonectomy (EPP) in Children and Adults with Locally Advanced Sarcoma: A CanSaRCC Study — C. Rodrigues, H. Peretz Soroka, et al. (2022)
• The recurrence of malignant pleural mesothelioma 14 years after extrapleural pneumonectomy: possible histological transformation — T. Kinoshita, G. Ishii, et al. (2012)
• Extrapleural pneumonectomy for sarcomas report of two cases — A.V. Bedini, L. Tavecchio, et al. (2000)
• 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)
• Extrapleural pneumonectomy for malignant pleural mesothelioma: outcomes of treatment and prognostic factors — T.D. Yan, M. Boyer, et al. (2009)
• Extrapleural pneumonectomy after induction chemotherapy: perioperative outcome in 251 mesothelioma patients from three high-volume institutions — O. Lauk, M.A. Hoda, et al. (2014)

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