Feasibility and safety of extended pleurectomy/decortication for malignant pleural mesothelioma. A single group experience

Our plain-English summary of Feasibility and safety of extended pleurectomy/decortication for malignant pleural mesothelioma. A single group experience, by F. Falanga, P. Rinaldi, C. Primiceri, et al (Thoracic Cancer, 2022).

The study

• Authors: F. Falanga, P. Rinaldi, C. Primiceri, C. Bortolotto, O. Oneta, F. Agustoni, P. Morbini, L. Saracino, D. Eleftheriou, F. Sottotetti, G.M. Stella
• Journal: Thoracic Cancer
• Published: 2022;13(19):2792-2798
• Cited by: 3 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Surgery is part of a multimodal therapeutic approach to malignant pleural mesothelioma (MPM) although its real beneficial effect is still controversial. The optimal precise sequence of treatments within the trimodality is unclear, and should be decided upon a multidisciplinary consensus for each individual patient. Here, we analyzed the perioperative data of 19 MPM patients who underwent extended pleurectomy/decortication (EPD) with curative intent. The mean age at diagnosis was 67 years; 11 males and eight females. Ten patients were diagnosed with MPM via medical thoracoscopy (MT), and nine via video-assisted thoracoscopic surgery (VATS). The vast majority of cases harbored epitheliod forms. We compared neoadjuvant chemotherapy (NCT) followed by surgery (11 cases) versus surgery followed by adjuvant chemotherapy (ACT, 8 cases) within a 3-year period. All patients had extended pleurectomy/decortication and none had an extended pneumonectomy. Analysis of survival curves suggested that the short-term outcomes are better with upfront EDP followed by ACT if compared to EDP preceded by NCT. Although limited, the data highlighted the safety and feasibility of EPD, with manageable postoperative complications and no major burden for the patients.

© 2022 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.

In plain English

This report from one hospital in Pavia, Italy, looked back at 19 patients with malignant pleural mesothelioma who had extended pleurectomy/decortication, a lung-sparing operation, between July 2019 and July 2021. Eleven had chemotherapy before surgery and eight had it after surgery. Asbestos exposure was recorded as environmental in 10 patients, occupational in 2 and none in 7. No major postoperative complications were reported. Four of the 19 needed intensive care observation and 3 had a persistent air leak; anemia was reported in 14 patients in the text but 13 in the table. Three months after surgery, the disease had progressed or come back in 8 of 11 chemotherapy-first patients and 1 of 8 surgery-first patients. Median disease-free survival was 13 months for surgery-first patients and 3 months for chemotherapy-first patients, each with a 95% confidence interval of 3 to 13 months (p = 0.13). The authors concluded that surgery before chemotherapy appeared more feasible, with lower postoperative morbidity and better short-term outcomes. They noted the small sample, the retrospective design, essentially epithelioid cases and no radiotherapy.

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 a consecutive series of surgical patients at a single center (brief report), comparing chemotherapy before surgery with surgery followed by chemotherapy
• Who was studied: 19 patients with malignant pleural mesothelioma (11 male, 8 female) who had extended pleurectomy/decortication at IRCCS Fondazione Policlinico San Matteo, Pavia, Italy, July 2019 to July 2021. Eleven were in the neoadjuvant chemotherapy then surgery group (NCT/EPD) and eight in the surgery then adjuvant chemotherapy group (EPD/ACT).
• Exposure: The study compared treatment sequences, not asbestos exposures. Asbestos exposure history was tabulated with no fiber types given. NCT/EPD group: none 4, environmental 6, occupational 1. EPD/ACT group: none 3, environmental 4, occupational 1. First-line chemotherapy was cisplatin plus pemetrexed in 18 patients and carboplatin plus gemcitabine in 1.
• Main results:
  • Among all 19 patients, no major postoperative complications were observed. Four (21%) required intensive care observation and 3 (16%) had a persistent air leak. The text gives anemia in 14 (74%) patients, but Table 1 lists 9 and 4 (13 in total). Average hospital stay after surgery was 12.6 days.
  • By group (Table 1): anemia in 9 of 11 NCT/EPD patients and 4 of 8 EPD/ACT patients. Intensive care observation in 3 of 11 NCT/EPD and 1 of 8 EPD/ACT. Persistent air leak in 1 NCT/EPD and 2 EPD/ACT. Mean postoperative stay was 11 days (NCT/EPD) and 14 days (EPD/ACT).
  • Progression or recurrence at 3 months after surgery: 8 of 11 NCT/EPD patients and 1 of 8 EPD/ACT patients. At 6 months: 8 of 11 NCT/EPD and 3 of 8 EPD/ACT.
  • Median disease-free survival was 6 months (95% CI 3 to 13) for the whole cohort, 13 months (95% CI 3 to 13) for EPD/ACT patients and 3 months (95% CI 3 to 13) for NCT/EPD patients, p = 0.13.
  • Median overall survival was 22.3 months (95% CI 16.5 to 28.1). Mean overall survival was 20.6 months (95% CI 13.6 to 27.6) for NCT/EPD and 18.9 months (95% CI 14.0 to 23.8) for the second group, which the text labels 'EPD/NCT', p = 0.44.
• The authors' conclusion: The authors concluded that EPD appeared more feasible before chemotherapy than after it, citing lower postoperative morbidity and better short-term outcomes. They described the data as limited but supporting the safety and feasibility of EPD.
• Limitations the authors state:
  • The sample size cannot guarantee statistical significance for most of the data.
  • Cases were essentially epithelioid, so no conclusion can be drawn on mixed or sarcomatoid mesothelioma.
  • The retrospective design may have influenced the results in favor of or against either group.
  • Differences in chemotherapy used after first-line treatment do not allow identification of the most efficient regimens.
  • No patient had radiotherapy, so no conclusions can be drawn about a full multimodal approach.

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: Pleurectomy/Decortication (P/D), Pleural Mesothelioma, Medical Thoracoscopy, Video-Assisted Thoracoscopic Surgery (VATS), Neoadjuvant Therapy, Chemotherapy, Pneumonectomy.

Related studies

• 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)
• Extended Pleurectomy/Decortication for Malignant Pleural Mesothelioma: Humanitas's Experience — G. Mangiameli, E. Bottoni, et al. (2021)
• A feasibility study of induction pemetrexed plus cisplatin followed by pleurectomy/decortication aimed at macroscopic complete resection for malignant pleural mesothelioma — M. Shimokawa, S. Hasegawa, et al. (2013)
• A randomised phase II study of extended pleurectomy/decortication preceded or followed by chemotherapy in patients with early-stage pleural mesothelioma: EORTC 1205 — J. Raskin, V. Surmont, et al. (2024)
• Effects of extended pleurectomy and decortication on quality of life and pulmonary function in patients with malignant pleural mesothelioma — D. Burkholder, D. Hadi, et al. (2015)
• Extended pleurectomy decortication for thymoma with pleural dissemination — N. Imanishi, Y. Nabe, et al. (2019)

Browse more research in Thoracic Cancer, or return to medical research.