Should Lung-Sparing Surgery Be the Standard Procedure for Malignant Pleural Mesothelioma?

Our plain-English summary of Should Lung-Sparing Surgery Be the Standard Procedure for Malignant Pleural Mesothelioma?, by Y. Ichiki, H. Goto, T. Fukuyama, et al (Journal of Clinical Medicine, 2020).

The study

• Authors: Y. Ichiki, H. Goto, T. Fukuyama, K. Nakanishi
• Journal: Journal of Clinical Medicine
• Published: 2020;9(7)
• Type of article: Review
• Cited by: 7 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Surgical procedures for malignant pleural mesothelioma (MPM) include extrapleural pneumonectomy (EPP), extended pleurectomy/decortication (P/D) and P/D. EPP has been applied to MPM for a long time, but the postoperative status is extremely poor due to the loss of one whole lung. We compared the mortality, morbidity and median survival time (MST) of lung-sparing surgery (extended P/D or P/D) and lung-sacrificing surgery (EPP) for MPM by performing a systematic review.

Methods: We extracted the number of events and patients from the literature identified in electronic databases. Ultimately, 15 reports were selected, and 2674 MPM patients, including 1434 patients undergoing EPP and 1240 patients undergoing extended P/D or P/D, were analyzed.

Results: Our systematic review showed that lung-sparing surgery was significantly superior to lung-sacrificing surgery in both the surgical-related mortality (extended P/D vs. EPP: 3.19% vs. 7.65%, p < 0.01; P/D vs. EPP: 1.85% vs. 7.34%, p < 0.01) and morbidity (extended P/D vs. EPP: 35.7% vs. 60.0%, p < 0.01; P/D vs. EPP: 9.52% vs. 20.89%, p < 0.01). Lung-sparing surgery was not inferior to EPP in terms of MST.

Conclusion: Although no prospective randomized controlled trial has been conducted, it may be time to change the standard surgical method for MPM from lung-sacrificing surgery to lung-sparing surgery.

In plain English

This article was a systematic review and meta-analysis of operations for malignant pleural mesothelioma; it did not study asbestos exposure. It compared extrapleural pneumonectomy (EPP), which removes the whole lung on the affected side, with lung-sparing surgery: pleurectomy/decortication (P/D) or extended P/D. The authors pooled 15 published reports covering 2674 patients: 1434 who had EPP and 1240 who had extended P/D or P/D. Death within 30 days was 3.19% after extended P/D versus 7.65% after EPP, and 1.85% after P/D versus 7.34% after EPP. Complication rates were 35.7% versus 60.0% (extended P/D versus EPP) and 9.52% versus 20.89% (P/D versus EPP). Each of these differences was statistically significant. For median survival, one of seven reports found significantly longer survival after extended P/D than after EPP. The other six, and all eight reports comparing P/D with EPP, found no significant difference. The authors concluded it may be time to make lung-sparing surgery the standard operation. They noted that all included studies were retrospective, that no randomized trial had compared these operations, and that endpoints and complication definitions varied.

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: Systematic review and meta-analysis of 15 published studies comparing surgical methods for malignant pleural mesothelioma
• Who was studied: 2674 patients with malignant pleural mesothelioma from 15 English-language papers published 1990 to 2020 and found in PubMed: 1434 had EPP and 1240 had extended P/D or P/D
• Exposure: Asbestos exposure was not studied. The comparison was between surgery types: lung-sacrificing extrapleural pneumonectomy (EPP) versus lung-sparing extended pleurectomy/decortication or pleurectomy/decortication (P/D)
• Main results:
  • 30-day mortality was 3.19% after extended P/D and 7.65% after EPP (p less than 0.01; pooled odds ratio 0.53, 95% CI 0.33 to 0.85)
  • Morbidity (complications) was 35.7% after extended P/D and 60.0% after EPP (p less than 0.01; pooled odds ratio 0.37, 95% CI 0.26 to 0.54), but heterogeneity among studies was detected (I2 = 64%)
  • Of seven papers comparing median survival for extended P/D versus EPP, only one found significantly longer survival with extended P/D; the other six found no significant difference
  • 30-day mortality was 1.85% after P/D and 7.34% after EPP (p less than 0.01; pooled odds ratio 0.26, 95% CI 0.13 to 0.52)
  • Morbidity was 9.52% after P/D and 20.89% after EPP (p less than 0.01; pooled odds ratio 0.42, 95% CI 0.25 to 0.71)
  • None of the eight papers comparing P/D with EPP found a significant difference in median survival; in four of them EPP had the longer median survival
• The authors' conclusion: The authors concluded that lung-sparing surgery was superior to EPP in surgery-related mortality and morbidity, and not inferior in median survival. They wrote that it may be time to change the standard operation for malignant pleural mesothelioma to lung-sparing surgery. They also acknowledged that no randomized controlled trial comparing the surgical methods had been performed.
• Limitations the authors state:
  • The included reports had different primary endpoints and different criteria for perioperative complications
  • Heterogeneity was found in the morbidity data for extended P/D versus EPP
  • Some papers did not clearly describe which surgical method was used
  • Only two papers were available to compare morbidity between P/D and EPP
  • All included studies were retrospective; none were prospective randomized controlled trials
  • No randomized controlled trial comparing the surgical methods for malignant pleural mesothelioma had been performed
  • Surgical indication factors (tumor type, TNM stage, patient age and heart and lung risk factors) and the quality of surgery varied between institutions and were not included in the analysis
  • Tumor histologic subtypes were not analyzed in detail, which may bias the survival comparison

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D), Median Overall Survival, Systematic Review.

Related studies

• Which is the Role of Pneumonectomy in the Era of Parenchymal-Sparing Procedures? Early/Long-Term Survival and Functional Results of a Single-Center Experience — A. Janet-Vendroux, M. Loi, et al. (2015)
• National Cancer Database Report on Pneumonectomy Versus Lung-Sparing Surgery for Malignant Pleural Mesothelioma — V. Verma, C.A. Ahern, et al. (2017)
• A systematic review of lung-sparing extirpative surgery for pleural mesothelioma — E. Teh, F. Fiorentino, et al. (2011)
• The Effects of Preserving the Diaphragm on Early and Late Outcome of Lung-Sparing Radical Surgery for Malignant Pleural Mesothelioma — M. Lee, L. Ventura, et al. (2022)
• Long-term outcomes after lung-sparing surgery for epithelial mesothelioma — C. Breda, S. Furia, et al. (2021)
• Safety and efficacy of helical tomotherapy following lung-sparing surgery in locally advanced malignant pleural mesothelioma — J.P. Layer, P. Fischer, et al. (2024)

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