Incidence and Risk Factors of Chest Wall Metastasis at Biopsy Sites in Patients with Malignant Pleural Mesothelioma

Our plain-English summary of Incidence and Risk Factors of Chest Wall Metastasis at Biopsy Sites in Patients with Malignant Pleural Mesothelioma, by M. Hashimoto, M. Yuki, K. Kitajima, et al (Cancers, 2022).

The study

• Authors: M. Hashimoto, M. Yuki, K. Kitajima, A. Fukuda, T. Nakamichi, A. Nakamura, A. Kuroda, S. Matsumoto, N. Kondo, A. Sato, K. Yamakado, T. Tsujimura, S. Hasegawa
• Journal: Cancers
• Published: 2022;14(18)
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

To investigate the incidence and risk factors of chest wall metastasis (CWM) at biopsy sites in patients with malignant pleural mesothelioma (MPM). This retrospective cohort study was conducted in 262 consecutive MPM patients who underwent multimodal treatment in which including neoadjuvant chemotherapy (NAC) and curative-intent surgery, from August 2009 to March 2021. CWM was evaluated radiologically (r-CWM) and pathologically (p-CWM). We also investigated the risk factors of p-CWM and the consistency between r-CWM and p-CWM. Of 262 patients, 25 patients were excluded from analysis due to missing data or impossibility of evaluation. Of the eligible 237 patients, pleural biopsy was performed via video-assisted thoracoscopic surgery in 197 (83.1%) and medical thoracoscopy in 40 (16.9%). Pleurodesis was performed after pleural biopsy in 74 patients (31.2%). All patients received NAC followed by curative-intent surgery. Radiological examination showed r-CWM in 43 patients (18.1%), while pathological examination showed p-CWM in 135 patients (57.0%). The incidence of p-CWM was significantly higher in the patients who received pleurodesis after pleural biopsy (77.0% vs. 47.9%, <0.001). Multivariate logistic regression analysis for p-CWM revealed that pleurodesis is an independent risk factor of p-CWM (adjusted hazard ratio, 3.46; 95% confidence interval, 1.84−6.52, <0.001). CWM at the biopsy site was pathologically proven in more than half of the patients (57.0%) who received NAC followed by curative-intent surgery, which was higher than the numbers diagnosed by radiological examinations (p-CWM: 57.0% vs. r-CWM: 18.1%). Pleurodesis after pleural biopsy is an independent risk factor of p-CWM.

In plain English

This single-hospital retrospective cohort study in Japan reviewed 262 consecutive patients with malignant pleural mesothelioma who had chemotherapy followed by curative-intent surgery between August 2009 and March 2021. Of these, 237 were analyzed. It measured how often the cancer had spread into the chest wall at the site of the diagnostic pleural biopsy. Scans before surgery showed this spread in 43 patients (18.1%). Microscope examination of the surgically removed biopsy site found it in 135 (57.0%). The scans picked up 23.0% of the microscope-confirmed cases. Spread was found in 77.0% of patients who had pleurodesis (sealing of the pleural space) after biopsy, compared with 47.9% of those who did not. In multivariate analysis the adjusted ratio for pleurodesis was 3.46 (95% confidence interval 1.84 to 6.52). The text calls this a hazard ratio and the table calls it an odds ratio. The authors concluded that pleurodesis after pleural biopsy was an independent risk factor. They noted the study was retrospective, at one institution, in selected patients, and that biopsy methods and pleurodesis agents were not standardized. The article did not address asbestos exposure.

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 (historical) cohort study at a single institution
• Who was studied: 262 consecutive patients with histologically proven malignant pleural mesothelioma treated with multimodal treatment (neoadjuvant chemotherapy then curative-intent surgery) at Hyogo College of Medicine Hospital, Japan, August 2009 to March 2021. 25 were excluded (14 without pathological examination of the biopsy site, 11 diagnosed by needle biopsy), leaving 237 analyzed: median age 67, 193 males.
• Exposure: Not asbestos exposure. The factors studied were the diagnostic pleural biopsy (by video-assisted thoracoscopic surgery in 197 patients or medical thoracoscopy in 40) and pleurodesis after biopsy (74 patients). Other clinical variables were also examined.
• Main results:
  • Of 237 analyzed patients, chest wall metastasis at the biopsy site was seen on scans before surgery (r-CWM) in 43 (18.1%). It was found on pathological examination (p-CWM) in 135 (57.0%).
  • Compared with pathology, radiological examination had a sensitivity of 23.0% and a specificity of 88.2%.
  • The positive predictive value of radiological examination was 72.1% and the negative predictive value was 46.4%.
  • p-CWM was found in 77.0% of patients who received pleurodesis after pleural biopsy, compared with 47.9% of those who did not (p less than 0.001).
  • In multivariate logistic regression, pleurodesis after pleural biopsy was an independent risk factor for p-CWM: adjusted ratio 3.46, 95% confidence interval 1.84 to 6.52. The text calls this a hazard ratio; Table 4 labels it OR.
  • Male sex was not statistically significant in the univariate analysis (p-CWM in 59.6% of males vs. 45.5% of females, p = 0.09). Neither was diagnosis by VATS biopsy (58.9% vs. 47.5% with medical thoracoscopy, p = 0.22).
  • Median follow-up was 30.9 months and median survival in the cohort was 40.8 months. The results section reports significantly shorter survival in patients with p-CWM (figures printed as 49.8 months vs. 37.4 months, p less than 0.05). The discussion describes this association as not significant.
• The authors' conclusion: The authors concluded that chest wall metastasis at the biopsy site was pathologically proven in more than half of patients, more often than radiological examination detected it (57.0% vs. 18.1%). They also concluded that pleurodesis was an independent risk factor of chest wall metastasis after pleural biopsy, and that further investigation is needed.
• Limitations the authors state:
  • Single-institution retrospective study of selected patients who had undergone multimodal treatment. Most mesothelioma patients would not qualify for this treatment.
  • The pleural biopsy procedure was not standardized.
  • The indication for pleurodesis and the agents used were not standardized. The authors said a prospective study is needed.
  • p-CWM was not graded by size, which the authors suggested might explain why a survival impact was not observed.
  • Only 2 patients received prophylactic radiation therapy, so its effect could not be evaluated.

Topics

Medical terms in this study, explained in our Lexicon: Metastasis, Biopsy, Pleural Mesothelioma, Cohort Study, Neoadjuvant Therapy, Pleural Biopsy, Video-Assisted Thoracoscopic Surgery (VATS), Medical Thoracoscopy.

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• Well-differentiated papillary mesothelioma with invasion to the chest wall — I. Torii, M. Hashimoto, et al. (2010)
• Salvage resection after immunotherapy for giant undifferentiated pleomorphic sarcoma of the chest wall — A. Nakamura, A. Kuroda, et al. (2025)
• Poor Prognostic Factors in Patients with Malignant Pleural Mesothelioma Classified as Pathological Stage IB According to the Eighth Edition TNM Classification — T. Takuwa, M. Hashimoto, et al. (2018)
• Complications and Predictive Factors for Air Leak > 10 Days with Neoadjuvant Chemotherapy Followed by Pleurectomy/Decortication for Malignant Pleural Mesothelioma — A. Nakamura, N. Kondo, et al. (2021)
• Utility of Site-Specific Biopsy for Diagnosis of Desmoplastic Malignant Mesothelioma — T. Sakai, K. Tane, et al. (2018)

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