Quantitation and predictors of short-term mortality following extrapleural pneumonectomy, pleurectomy/decortication, and nonoperative management for malignant pleural mesothelioma

Our plain-English summary of Quantitation and predictors of short-term mortality following extrapleural pneumonectomy, pleurectomy/decortication, and nonoperative management for malignant pleural mesothelioma, by C. Wright, V. Verma, A.R. Barsky, et al (Journal of Thoracic Disease, 2020).

The study

• Authors: C. Wright, V. Verma, A.R. Barsky, W. Haque, P.V. Polamraju, E.B. Ludmir, N.G. Zaorsky, E.J. Lehrer, D.M. Trifiletti, S. Grover, J.S. Friedberg, C.B. Simone
• Journal: Journal of Thoracic Disease
• Published: 2020;12(11):6476-6493
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: For malignant pleural mesothelioma (MPM), the benefit of resection, as well as the optimal surgical technique, remain controversial. In efforts to better refine patient selection, this retrospective observational cohort study queried the National Cancer Database in an effort to quantify and evaluate predictors of 30- and 90-day mortality between extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D), as well as nonoperative management.

Methods: After applying selection criteria, cumulative incidences of mortality by treatment paradigm were graphed for the unadjusted and propensity-matched populations, as well as for six a priori age-based intervals (≤60, 61-65, 66-70, 71-75, 76-80, and ≥81 years). The interaction between age and hazard ratio (HR) for mortality between treatment paradigms was also graphed. Cox multivariable analysis ascertained factors independently associated with 30- and 90-day mortality.

Results: Of 10,723 patients, 2,125 (19.8%) received resection (n=438 EPP, n=1,687 P/D) and 8,598 (80.2%) underwent nonoperative management. The unadjusted 30/90-day mortality for EPP, P/D, and all operated cases was 3.0%/8.0%, 5.4%/14.1%, and 4.9%/12.8%, respectively. There were no short-term mortality differences between EPP and P/D following propensity-matching, within each age interval, or between age subgroups on interaction testing (P>0.05 for all). Nonoperative patients had a crude 30- and 90-day mortality of 9.9% and 24.6%, respectively. Several variables were identified as predictors of short-term mortality, notably patient age (HR 1.022, P<0.001), Charlson-Deyo comorbidity index (HR 1.882, P<0.001), receipt of treatment at high-volume centers (HR 0.834, P=0.032) and induction chemotherapy (HR 1.735, P=0.025), among others. The patient (yearly) incremental increase in age conferred 2.0% (30 day) and 2.2% (90 day) increased risk of mortality (P<0.001).

Conclusions: Quantitative estimates of age-associated 30- and 90-day mortality of EPP and P/D should be considered when potentially operable patients are counseled regarding the risks and benefits of resection.

2020 Journal of Thoracic Disease. All rights reserved.

In plain English

This retrospective cohort study used the US National Cancer Database to measure deaths within 30 and 90 days among people with malignant pleural mesothelioma. Of 10,723 patients, 438 had extrapleural pneumonectomy (EPP), 1,687 had pleurectomy/decortication (P/D) and 8,598 had no surgery. Within 30 days, 3.0% of EPP and 5.4% of P/D patients died. Within 90 days, the figures were 8.0% and 14.1%. The overall difference between the two operations did not persist after statistical matching (P=0.193), and no difference was found within any of six age groups. Among patients without surgery, with time counted from diagnosis, 9.9% died within 30 days and 24.6% within 90 days. Each added year of age was associated with a 2.0% higher risk of death at 30 days and 2.2% at 90 days. Treatment at high-volume centers was associated with lower mortality, and among surgical patients, induction chemotherapy was associated with higher mortality. The authors concluded that these age-associated estimates should be considered when counseling potentially operable patients. They cautioned that the data are confounded by operability status.

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 cohort study of a US national cancer registry (National Cancer Database), with propensity matching and Cox multivariable analysis
• Who was studied: 10,723 patients with malignant pleural mesothelioma in the US National Cancer Database (mesothelioma file 2004–2013). Of these, 2,125 had surgery (438 EPP, 1,687 P/D) and 8,598 had nonoperative management. Patients with T4 (unresectable) or metastatic disease were excluded.
• Exposure: Treatment type: extrapleural pneumonectomy, pleurectomy/decortication, or nonoperative management (chemotherapy, radiotherapy, chemoradiotherapy, or supportive care). Asbestos exposure was not studied.
• Main results:
  • Crude 30-day mortality was 3.0% for EPP and 5.4% for P/D. Crude 90-day mortality was 8.0% for EPP and 14.1% for P/D.
  • All resected patients combined had unadjusted 30-day mortality of 4.9% and 90-day mortality of 12.8%.
  • EPP and P/D did not differ in short-term mortality within any of the six age groups.
  • Across all surgical patients there was a statistical difference between EPP and P/D (P=0.001), but it did not persist after propensity matching (P=0.193).
  • Interaction testing found that the EPP versus P/D effect size did not differ significantly between the six age groups, at 30 days or at 90 days.
  • Nonoperative patients had crude mortality of 9.9% at 30 days and 24.6% at 90 days. For this group, time was measured from diagnosis, not from surgery.
  • In the multivariable analysis, each yearly increase in age at diagnosis was associated with a 2.0% increased risk of 30-day mortality and a 2.2% increased risk of 90-day mortality (P<0.001).
  • Surgical patients who received induction chemotherapy had higher mortality (90-day HR 1.735, 95% CI 1.071–2.811, P=0.025). Treatment at high-volume centers was associated with less mortality (90-day HR 0.834 for the highest volume quartile, P=0.032).
  • A Charlson-Deyo comorbidity index of 2 or more was associated with higher 30-day mortality in the multivariable analysis (HR 1.882, 95% CI 1.567–2.261).
• The authors' conclusion: The authors concluded that their age-associated 30- and 90-day mortality estimates for EPP and P/D should be considered when potentially operable patients are counseled about the risks and benefits of resection.
• Limitations the authors state:
  • The data are confounded by operability status: surgical patients were well selected, and most nonoperative patients were unresectable or inoperable.
  • Mortality risk for potentially operable patients who decline surgery cannot be estimated from the nonoperative group.
  • It is not known whether short-term deaths were caused by the treatment, because the database does not record complications or causes of death.
  • Patients who died after induction chemotherapy but before surgery would have been counted in the nonoperative group.
  • Important factors such as performance status and cardiopulmonary function are not recorded in the database.
  • The criteria used to choose between surgical approaches are not available.
  • Only accredited facilities contribute data, so the findings may not represent the whole US population.

Topics

Medical terms in this study, explained in our Lexicon: Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D), Pleural Mesothelioma, Cohort Study, Hazard Ratio, High-Volume Center, Chemotherapy.

Related studies

• Short-term outcomes of pleurectomy decortication and extrapleural pneumonectomy in mesothelioma — M. van Gerwen, A. Wolf, et al. (2018)
• 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)
• Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma — L. Lang-Lazdunski, A. Bille, et al. (2012)
• VATS Pleurectomy Decortication Is a Reasonable Alternative for Higher Risk Patients in the Management of Malignant Pleural Mesothelioma: An Analysis of Short-Term Outcomes — D.S. Lee, A. Carollo, et al. (2021)
• Pleurectomy/Decortication Versus Extrapleural Pneumonectomy in Pleural Mesothelioma: A Systematic Review and Meta-Analysis of Survival, Mortality, and Surgical Trends — M. Brivio, M. Chiari, et al. (2025)
• Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma — E. Taioli, A.S. Wolf, et al. (2015)

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