Quality of Life Is Not Deteriorated After Extrapleural Pneumonectomy vs. (Extended) Pleurectomy/Decortication in Patients With Malignant Pleural Mesothelioma

Our plain-English summary of Quality of Life Is Not Deteriorated After Extrapleural Pneumonectomy vs. (Extended) Pleurectomy/Decortication in Patients With Malignant Pleural Mesothelioma, by O. Lauk, M. Patella, T. Neuer, et al (Frontiers in Surgery, 2021).

The study

• Authors: O. Lauk, M. Patella, T. Neuer, I. Inci, W. Weder, I. Opitz
• Journal: Frontiers in Surgery
• Published: 2021;8:766033
• Cited by: 4 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM) is highly abandoned due to high morbidity and mortality rates and impaired quality of life (QoL). However, there are still rare indications for this intervention. The aim of this longitudinal prospective study was to monitor QoL and lung function in patients undergoing EPP and compare the outcomes with extended pleurectomy/decortication [(E)PD]. Methods: Between June 2013 and June 2017, 42 patients underwent induction chemotherapy followed by either EPP (n = 7) or (E)PD (n = 35). All patients filled out the EORTC QLC-C15-PAL, -LC13, and SF-36 self-rating questionnaires pre-operatively, 6 weeks and 4 months after the operation. Additionally, lung function was measured pre-operatively and 4 months post-operatively. Results: We observed no significant differences in all QoL categories (general global health, pain, and dyspnea) between both surgical procedures, over the whole observation period. Moreover, a general tendency toward restoration of the pre-operative QoL status was documented at 4 months after the both operations. Forced expiratory volume in 1 s (FEV1) showed a significant decrease after surgery in both the groups [EPP group p = 0.06 and (E)PD group p < 0.001]; also, the forced volume vital capacity (FVC) significantly decreased (EPP group p = 0.046 P/D group <0.001). Diffusion capacity did not show significant changes. Conclusion: According to these results, QoL is no longer severely impaired after EPP compared with EPD, and therefore should not be used as an argument against EPP in principle. However, indication has to be carefully evaluated for each patient.

Copyright © 2021 Lauk, Patella, Neuer, Inci, Weder and Opitz.

In plain English

This study from University Hospital Zurich followed 42 patients with malignant pleural mesothelioma who had induction chemotherapy and then surgery between 2013 and 2017. Seven had extrapleural pneumonectomy (EPP) and 35 had (extended) pleurectomy/decortication ((E)PD). The article does not report asbestos exposure. Patients completed three quality-of-life questionnaires before surgery and 6 weeks and 4 months after. Lung function was tested before surgery and at 4 months. Quality of life did not differ significantly between the groups, though the authors described a trend favoring (E)PD. FEV1, a lung function measure given as percent of predicted normal, fell from 76% to 48% after EPP and from 82% to 65% after (E)PD. Only the (E)PD decrease was statistically significant. The article reported 0% mortality at 90 days for both procedures, but Table 1 lists 90-day data as unavailable for two of the seven EPP patients. The authors concluded that EPP should not be abandoned for quality-of-life reasons if medically indicated. They noted the short follow-up, the small EPP group, and no adjustment for confounders.

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: Single-centre study of prospectively collected quality-of-life questionnaires and lung function tests, comparing two surgical procedures; the authors call it a correlative, not causal, analysis
• Who was studied: 42 of 71 patients with malignant pleural mesothelioma who had macroscopic complete resection after induction chemotherapy at University Hospital Zurich, 2013 to 2017. 29 were excluded for early relapse or death, loss to follow-up or a missing pre-operative questionnaire, or language problems. Median age at surgery was 65 years.
• Exposure: No asbestos exposure was studied. The comparison was between two operations after induction chemotherapy: extrapleural pneumonectomy (EPP, n = 7) and (extended) pleurectomy/decortication ((E)PD, n = 35).
• Main results:
  • Quality of life did not differ significantly between the (E)PD and EPP groups at 6 weeks or 4 months after surgery.
  • In the difference-in-differences analysis (change from before surgery to 4 months), there were no significant differences between groups. There was a trend toward higher quality of life in the (E)PD group on the SF-36 questionnaire.
  • FEV1 (percent of predicted) fell from 76% to 48% in the EPP group and from 82% to 65% in the (E)PD group. The fall was statistically significant only for the (E)PD group (p < 0.001).
  • FVC fell from 78% to 52% in the EPP group and from 84% to 66% in the (E)PD group.
  • Diffusing capacity (DLCO) fell from 75% to 63% in the (E)PD group (p < 0.001). In the EPP group it fell from 73% to 55%, which was not statistically significant.
  • Median overall survival was 21 months in the EPP group (95% CI: 0.12-NA) and 33 months in the (E)PD group (95% CI: 23-NA).
  • The article reported 30-day and 90-day mortality of 0% for both procedures.
  • Table 1 lists 90-day mortality data as not available for 2 of the 7 EPP patients (29%), so the 0% figure for that group covers only patients with available data.
• The authors' conclusion: The authors concluded that, in their data, quality of life after EPP did not show an impairment compared with (E)PD, so EPP should not be abandoned for quality-of-life reasons if medically indicated. They also wrote that their results showed a trend in favor of (E)PD, which should be the favored approach whenever feasible.
• Limitations the authors state:
  • Short post-operative observation time, with follow-up limited to 4 months
  • The lack of a statistically significant difference was probably due to the small EPP group, so the data are only indicative
  • No adjustment for confounders and no causal conclusions possible
  • The small sample size does not allow causal conclusions

Topics

Medical terms in this study, explained in our Lexicon: Quality of Life, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D), Pleural Mesothelioma, Chemotherapy, Dyspnea, FEV1.

Related studies

• Systematic review of quality of life following pleurectomy decortication and extrapleural pneumonectomy for malignant pleural mesothelioma — R.M. Schwartz, W. Lieberman-Cribbin, et al. (2018)
• 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)
• Anaesthetic and perioperative considerations for extrapleural pneumonectomy and extended pleurectomy/decortication: a scoping review protocol — S.W.S. Yip, L. Weinberg, et al. (2024)
• Quality of life after radical pleurectomy decortication for malignant pleural mesothelioma — N.M. Mollberg, Y. Vigneswaran, et al. (2012)
• Influence of Pleurectomy and Decortication in Health-Related Quality of Life Among Patients with Malignant Pleural Mesothelioma — W.T. Vigneswaran, D.Y. Kircheva, et al. (2018)
• Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma — E. Taioli, A.S. Wolf, et al. (2015)

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