Long-term outcomes after lung-sparing surgery for epithelial mesothelioma

Our plain-English summary of Long-term outcomes after lung-sparing surgery for epithelial mesothelioma, by C. Breda, S. Furia, G. Lucchini, et al (Journal of Thoracic Disease, 2021).

The study

• Authors: C. Breda, S. Furia, G. Lucchini, A. Zaccaria, E. Verderi, G. Natale, F. Lo Giudice, R. Cavallin, A. Ferronato, P. Fontana
• Journal: Journal of Thoracic Disease
• Published: 2021;13(11):6283-6293
• Cited by: 3 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: This observational study evaluates retrospectively the long-term outcomes after pleurectomy/decortication for pleural mesothelioma, with and without the resection/reconstruction of diaphragm and pericardium.

Methods: Data from 155 consecutive patients undergoing lung-sparing surgery for epithelial pleural mesothelioma were reviewed. Selection criteria for surgery were cT1-3, cN0-1, good performance status, age <80 years. Perioperative Pemetrexed-Platinum regimen was administered as induction in 101 cases (65.2%) and as adjuvant treatment in 54 cases (34.8%). Extended pleurectomy/decortication was performed in 87 cases (56.12%). In 68 patients (43.87%) standard pleurectomy/decortication was performed without resection/reconstruction of diaphragm and pericardium, when tumour infiltration was deemed absent after intraoperative frozen section. The log-rank test and Cox regression model were used to assess the factors affecting overall survival and recurrence free survival.

Results: Median follow-up was 20 months. The 2- and 5-year survival rate was 60.9% and 29.2% with a median survival of 34 months. An improved survival was observed when standard pleurectomy/decortication was carried out (P=0.007). A significant impact on survival was found comparing the TNM-stages (P=0.001), pT (P=0.002) and pN variables (P=0.001). Multivariate analysis identified the pN-status (P=0.003) and standard pleurectomy/decortication (P=0.017) as predictive for longer survival. The recurrence-free survival >12 months was strongly related to the overall survival (P<0.001). The macroscopic complete resection (P=0.001), TNM-stage (P=0.003) and pT-status (P=0.001) are related to relapse.

Conclusions: Within multimodal management of pleural mesothelioma, lung-sparing surgery is a valid option even with more conservative technique. A benefit for a longer survival was observed in the early stage of disease, with pN0 and when pleurectomy/decortication is carried out, preserving diaphragm and pericardium. Recurrence is not affected by the type of surgery, and a recurrence-free interval >12 months is predictive of an increased survival when the macroscopic complete resection is achieved.

2021 Journal of Thoracic Disease. All rights reserved.

In plain English

This retrospective study reviewed 155 patients with epithelial pleural mesothelioma who had lung-sparing surgery at one unit in Venice Mestre, Italy, in 2009 to 2019. Asbestos exposure was recorded for 85.2% (occupational, environmental or household). Surgeons performed standard pleurectomy/decortication (P/D), preserving the diaphragm and pericardium, in 68 patients, and extended P/D, resecting and reconstructing the diaphragm, pericardium or both, in 87. The choice rested on operative findings, including frozen sections. Median overall survival from surgery was 34 months (95% CI 25.2 to 42.8): 49 (33.34 to 64.66) after standard P/D and 22 (16.38 to 27.61) after extended P/D (P=0.007). In multivariate analysis, surgery type and lymph-node status were independently associated with survival. Among 129 patients with recurrence data, median recurrence-free survival was 26 months (19.72 to 32.28) after standard P/D and 15 months (9.40 to 20.60) after extended P/D, a difference not statistically significant. Incomplete (R2) surgery was associated with relapse. The authors concluded that survival benefits were observed when the diaphragm and pericardium were preserved, and called for further studies. They noted possible bias from the retrospective single-centre design.

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 observational study at a single centre
• Who was studied: 155 patients with epithelial malignant pleural mesothelioma who had lung-sparing surgery at the Thoracic Surgery Unit, Venice Mestre, Italy, 2009 to 2019. The centre performed 207 consecutive procedures; 28 patients with biphasic histotype were excluded and 24 were lost to follow-up. Mean age was 64.3 years and 77.4% were male.
• Exposure: The comparison studied was the type of surgery: standard P/D (n=68) versus extended P/D (n=87), defined as large resections requiring prosthetic reconstruction of the pericardium, the diaphragm or both. All patients also received 3 to 6 cycles of pemetrexed plus platinum chemotherapy, as induction (101) or adjuvant (54) treatment. Asbestos exposure was reported only as a baseline characteristic: 132 (85.2%) exposed in total, comprising professional 94 (60.6%), environmental 33 (21.3%) and household 5 (3.2%); exposure was uncertain in 23 (14.8%). No fiber types were reported.
• Main results:
  • All 155 patients: median overall survival 34 months (95% CI 25.2 to 42.8); 2-year survival 60.9% and 5-year survival 29.2%. Median follow-up was 20 months.
  • Median overall survival was 49 months after standard P/D (95% CI 33.34 to 64.66) and 22 months after extended P/D (95% CI 16.38 to 27.61); the log-rank P was 0.007.
  • 2-year and 5-year survival: 75.5% and 41.6% after standard P/D, and 48.3% and 19.8% after extended P/D.
  • 2-year and 5-year survival: 68.9% and 39.5% in patients without lymph-node involvement (N0), and 40.5% and 16.6% in patients with node involvement (N1).
  • Multivariate analysis of overall survival: standard P/D and pN0 were independent prognostic factors (P/D vs. EP/D hazard ratio 1.746, 95% CI 1.105 to 2.758, P=0.017; pN0 vs. pN1 hazard ratio 2.038, 95% CI 1.281 to 3.241, P=0.003).
  • Recurrence-free survival was analysed in 129 patients. Overall median was 20 months. It was 26 months after standard P/D (95% CI 19.72 to 32.28) and 15 months after extended P/D (95% CI 9.40 to 20.60); this difference was not statistically significant.
  • In multivariate analysis, incomplete (R2) surgery was the only variable independently associated with relapse (hazard ratio 2.593, 95% CI 1.474 to 4.558, P=0.001).
  • The 74 patients (57.36%) whose first relapse came more than 12 months after surgery had a median survival of 30 months, compared with 9 months for the others (P<0.001).
  • Postoperative mortality for all patients was 0.64% at 30 days and 3.2% at 90 days.
• The authors' conclusion: The authors concluded that survival benefits were observed when the diaphragm and pericardium were preserved, and that recurrence-free survival seemed not to be affected by the type of surgery. They stated that further studies are needed to confirm whether systematic replacement of the diaphragm and pericardium might be avoided when no tumour infiltration is present.
• Limitations the authors state:
  • Retrospective analysis over 10 years at a single centre. Changes over time in treatment strategy, TNM grouping and guideline recommendations may have introduced bias.
  • Pathological staging defined by the surgeons during pleurectomy may be a source of bias.

Topics

Medical terms in this study, explained in our Lexicon: Mesothelioma, Pleurectomy/Decortication (P/D), Pleural Mesothelioma, Diaphragm, Pericardium, Performance Status, Pemetrexed (Alimta), Frozen Section.

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