Salvage pleurectomy/decortication following immunotherapy for malignant pleural mesothelioma

Our plain-English summary of Salvage pleurectomy/decortication following immunotherapy for malignant pleural mesothelioma, by M. Takenaka, K. Kuroda, K. Yoshimatsu, et al (Interdisciplinary Cardiovascular and Thoracic Surgery, 2024).

The study

• Authors: M. Takenaka, K. Kuroda, K. Yoshimatsu, M. Mori, M. Kanayama, A. Taira, T. Kuwata, F. Tanaka
• Journal: Interdisciplinary Cardiovascular and Thoracic Surgery
• Published: 2024;38(2)
• Cited by: 3 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Salvage surgery following immunotherapy is a promising treatment option for advanced malignant tumour. However, only a few cases of salvage surgery for malignant pleural mesothelioma (MPM) have been reported. This retrospective study was conducted to assess the feasibility of salvage surgery following immunotherapy for initially unresectabele MPM. Among 61 patients who received pleurectomy/decortication (P/D) for MPM, 7 patients received salvage P/D after immunotherapy. Surgical indication of salvage P/D was conversion to resectability in 5 patients and local relapse in 2 patients, and macroscopic complete resection was achieved in all patients. Although salvage P/D was associated with longer operation time (median, 507 min), higher intraoperative blood loss (median, 2573 mL) and higher morbidity (≥ grade 3, 29%), no patient died after surgery. Radiographic response to immunotherapy was well correlated with pathologic response, as all 4 patients with partial response showed significant pathologic response (viable cells, ≤50%). With the median postoperative follow-up duration of 9.0 months, all patients were alive mostly without tumour recurrence as local recurrence developed in 1 patient. To conclude, salvage P/D after immunotherapy may be a feasible treatment option for selected patients with advanced MPM, which should be validated in future multi-institutional studies. In addition, a long-term follow-up is essential to reveal the clinical benefit achieved with salvage P/D following immunotherapy.

© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.

In plain English

This retrospective study from one surgical department in Kitakyushu, Japan, reviewed 61 patients with malignant pleural mesothelioma who had pleurectomy/decortication (P/D), surgery to remove the lining around the lung, between January 2017 and March 2023. Seven had 'salvage' P/D after immunotherapy: nivolumab plus ipilimumab in 5, and nivolumab after chemotherapy in 2. They were operated on because their disease became removable (5) or because it returned locally (2). The article did not report the patients' asbestos exposure. All visible tumour was removed in all 7. Median operation time was 507 minutes, against 375 minutes for the other 54 patients (P=0.030). Blood loss and serious complications were higher in the salvage group, but these differences were not statistically significant. No patient died within 30 days. In the 4 patients whose tumours shrank on scans, 50% or less of tumour cells remained alive. After a median of 271 days, all 7 were alive, and one had local recurrence. The authors called these preliminary results suggesting feasibility in highly selected patients. They noted the small single-centre sample and an unclear survival benefit.

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 single-institution study (brief communication) of surgical patients, comparing salvage P/D after immunotherapy with non-salvage P/D
• Who was studied: 61 patients who had curative-intent surgery (P/D in all) for malignant pleural mesothelioma at the Second Department of Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan, from January 2017 to March 2023. Seven had salvage P/D after immunotherapy (all male, median age 64.0, range 47 to 77). The other 54 had P/D for initially resectable disease.
• Exposure: The exposure studied was treatment, not asbestos: immunotherapy before salvage P/D (nivolumab plus ipilimumab in 5 patients; nivolumab following chemotherapy in 2 patients). The article does not report the patients' asbestos exposure.
• Main results:
  • Five of the 7 salvage patients had surgery because their disease was judged resectable after immunotherapy. In 4 of these, the reason was a partial response seen on scans.
  • Two of the 7 salvage patients had surgery for local relapse after immunotherapy.
  • Macroscopic complete resection was achieved in all 7 salvage P/D patients.
  • Median operation time was 507 minutes in the salvage P/D group versus 375 minutes in the non-salvage group (P = 0.030).
  • Median blood loss was 2573 ml (range 420 to 5900) in the salvage group versus 1804 ml (range 490 to 4210) in the non-salvage group (P-value 0.269). The authors wrote only that blood loss 'might be higher'.
  • Grade 3 or higher postoperative adverse events occurred in 2 of 7 salvage patients (28.6%) versus 7 of 54 non-salvage patients (13.0%) (P-value 0.273). The two salvage events were pneumonitis, and persistent air leak followed by empyema.
  • No patient in either group died within 30 days after surgery.
  • In 4 salvage patients, all of whom had a significant radiographic response, 50% or less of tumour cells in the removed tissue were viable (0%, less than 1%, 20% and 50%).
  • In the 3 salvage patients with no radiographic response, more than 50% of tumour cells remained viable.
  • At a median follow-up of 271 days, all 7 salvage patients were alive.
  • One of the 7 salvage patients developed local tumour recurrence. The others were alive without recurrence.
• The authors' conclusion: The authors concluded that salvage P/D following immunotherapy may be a feasible option for highly selected patients with initially unresectable malignant pleural mesothelioma. They described the results as preliminary and said they should be validated in future multi-institutional studies with long-term follow-up.
• Limitations the authors state:
  • Only 7 patients from a single institution were analysed retrospectively.
  • Statistical comparisons between the salvage and non-salvage groups may be biased because the two groups were very different from each other.
  • Salvage surgery involved longer operation time, higher blood loss and more serious complications. The authors attributed this partly to difficult dissection, probably caused by severe adhesions after immunotherapy.
  • Whether salvage P/D gives a significant survival benefit remains unclear, since immunotherapy alone may give long-term benefit. Long-term follow-up is needed.

Topics

Medical terms in this study, explained in our Lexicon: Pleurectomy/Decortication (P/D), Immunotherapy, Pleural Mesothelioma.

Related studies

• Salvage Pleurectomy/Decortication After Immunotherapy for Sarcomatoid Malignant Pleural Mesothelioma — K. Kajiyama, A. Taira, et al. (2023)
• Non-incisional pleurectomy/decortication for malignant pleural mesothelioma — F. Tanaka, M. Takenaka, et al. (2021)
• Surgical indications for pleurectomy/decortication in pleural mesothelioma based on the newly revised 9th edition of the tumour-node-metastasis classification — M. Kanayama, M. Takenaka, et al. (2024)
• 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)
• Pharmacokinetics of Hyperthermic Intrathoracic Chemotherapy following Pleurectomy and Decortication — P.H. Sugarbaker, O.A. Stuart, et al. (2012)
• Strategies to reduce morbidity following pleurectomy and decortication for malignant pleural mesothelioma — P. Bou-Samra, A. Chang, et al. (2023)

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