Single-Center 20-Year Experience in Surgical Treatment of Malignant Pleural Mesothelioma

Our plain-English summary of Single-Center 20-Year Experience in Surgical Treatment of Malignant Pleural Mesothelioma, by G. Mangiameli, E. Bottoni, U. Cariboni, et al (Journal of Clinical Medicine, 2022).

The study

• Authors: G. Mangiameli, E. Bottoni, U. Cariboni, G.M. Ferraroli, E. Morenghi, V.M. Giudici, E. Voulaz, M. Alloisio, A. Testori
• Journal: Journal of Clinical Medicine
• Published: 2022;11(15)
• Cited by: 7 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Objectives: We examined a series of malignant pleural mesothelioma (MPM) patients who consecutively underwent surgery in our institution during the last 20 years. Across this period, we changed our surgical approach to MPM, adopting extended pleurectomy and decortication (eP/D) instead of extrapleural pneumonectomy (EPP). In this study, we compare the perioperative outcomes and long-term survival of patients who underwent EPP vs. eP/D. Methods: A retrospective analysis was carried out of all the MPM patients identified from our departmental database who underwent EPP or P/D from 2000 to 2021. Clavien−Dindo criteria was adopted to score postoperative complications, while Kaplan−Meier methods and a Cox multivariable analysis were used to perform the survival analysis. Results: Of 163 patients, 78 (48%) underwent EPP and 85 (52%) eP/D. Induction chemotherapy was significantly administrated more often in the eP/D group (88% vs. 51%). Complete trimodality treatment including induction chemotherapy, radical surgery, and adjuvant radiotherapy was administered in 74% of the eP/D group versus 32% of the EPP group (p < 0.001). The postoperative morbidity rate was higher in the eP/D group (54%) compared to the EPP group (36%) (p = 0.02); no statistically significant differences were identified concerning major complications (EPP 43% vs. eP/D 24%, p = 0.08). No statistical differences were identified in 30-day mortality, 90-day mortality, median disease-free, and overall survival statistics between the two groups. The Cox multivariable analysis confirmed no induction chemotherapy (HR, 0.5; p = 0.002), RDW (HR, 1.08; p = 0.02), and the presence of pathological nodal disease (HR, 1.99; p = 0.001) as factors associated with worse survival in the entire series. Conclusions: Our data support that eP/D is a well-tolerated procedure allowing the implementation of a trimodality strategy (induction chemotherapy, surgery, and radiotherapy) in most MPM patients. When eP/D is offered in this setting, the oncological results are comparable to EPP. To obtain the best oncological results, the goal of surgical resection should be macroscopic complete resection (R0) in carefully selected patients (clinical N0).

In plain English

This single-hospital retrospective study in Rozzano, Italy, covered 163 patients operated on for malignant pleural mesothelioma from 2000 to April 2021. The hospital moved from extrapleural pneumonectomy (EPP, 78 patients) to extended pleurectomy and decortication (eP/D, 85 patients). Asbestos exposure was recorded in 75 of 75 EPP patients and 75 of 80 eP/D patients. More eP/D patients received induction chemotherapy (88.2% vs 53.8%) and full chemotherapy-surgery-radiotherapy treatment (74.1% vs 32%). Any complication was more common after eP/D (54.1% vs 35.9%), but major complications showed no statistically significant difference. Deaths within 30 days (1.3% EPP vs 2.3% eP/D) and 90 days (5.1% vs 3.5%) were similar. Median overall survival (28.1 months EPP, 25.5 eP/D) did not differ detectably by surgery type. Across all patients, induction chemotherapy was linked to longer survival; lymph node involvement, higher RDW (a red blood cell measure) and longer operations to shorter survival. The authors concluded that eP/D was well tolerated and that, offered within multimodality treatment, it gave cancer outcomes comparable to EPP. The main stated limitation was the retrospective, 20-year 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 single-center study of consecutive patients comparing two types of radical surgery
• Who was studied: 163 adults with malignant pleural mesothelioma who had radical cytoreductive surgery at IRCCS Humanitas Research Hospital, Rozzano, Italy, from 2000 to April 2021: 78 had EPP and 85 had eP/D
• Exposure: The study compared two operations, extrapleural pneumonectomy (EPP) and extended pleurectomy and decortication (eP/D), often combined with induction chemotherapy and postoperative radiotherapy. Asbestos exposure was recorded in 75/75 EPP patients (100%) and 75/80 eP/D patients (93.7%). No fiber types or doses were given.
• Main results:
  • Induction chemotherapy was given more often in the eP/D group than in the EPP group (88.2% vs. 53.8%, p < 0.001).
  • Complete trimodality treatment was given to 74.1% of the eP/D group and 32% of the EPP group (p < 0.001).
  • Any Clavien–Dindo complication occurred in 28 (35.9%) EPP and 46 (54.1%) eP/D patients (p = 0.02). The difference in major complications was not statistically significant. The abstract gives these as EPP 43% vs. eP/D 24%, p = 0.08.
  • 30-day mortality was 1.3% (EPP) vs. 2.3% (eP/D), p = 1.000. 90-day mortality was 5.1% vs. 3.5%, p = 0.711.
  • Median disease-free survival was 14.6 months (EPP) vs. 13.7 months (eP/D). Median overall survival was 28.1 months (EPP) vs. 25.5 months (eP/D). Neither difference was significant.
  • In the Cox analysis, the type of surgery (EPP vs. eP/D) showed no detected difference in disease-free or overall survival. For overall survival, the hazard ratio for EPP was 1.27 (95% CI 0.87–1.85, p = 0.209).
  • In the whole cohort, multivariable analysis for overall survival gave these results: induction therapy HR 0.50 (0.32–0.78, p = 0.002); RDW HR 1.08 (1.01–1.15, p = 0.020); operation time HR 1.23 (1.03–1.48, p = 0.023); pathological node involvement (pN+) HR 1.99 (1.34–2.95, p = 0.001).
  • For disease-free survival, multivariable analysis of the whole cohort gave: induction chemotherapy HR 0.55 (0.37–0.81, p = 0.003); pT3-4 HR 2.01 (1.26–3.23, p = 0.004); pN+ HR 1.54 (1.03–2.33, p = 0.038).
  • Recurrence was higher in the EPP group than in the eP/D group (81% vs. 67%, p = 0.046). The authors attributed this probably to the longer follow-up in the EPP group.
  • Asbestos exposure was not significantly associated with disease-free survival (HR 1.17, 95% CI 0.54–2.52, p = 0.693) or overall survival (HR 0.85, 95% CI 0.39–1.83, p = 0.675) in the univariable analyses of the whole cohort.
• The authors' conclusion: The authors concluded that eP/D was well tolerated and allowed trimodality treatment in most patients. When offered in a multimodality treatment setting, eP/D had oncological results comparable to EPP. They also said surgery should aim at macroscopic complete resection in carefully selected patients (epithelioid histology and clinical N0).
• Limitations the authors state:
  • The study was retrospective and covered about 20 years, during which unknown confounding variables, changing treatment and changing patient selection played a role.
  • Newer prognostic variables from the 2021 WHO classification, such as nuclear grading and frequently altered genes, were not investigated.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Extrapleural Pneumonectomy (EPP), Chemotherapy, Overall Survival, Surgical Resection.

Related studies

• Should we continue to offer extrapleural pneumonectomy to selected mesothelioma patients? A single center experience comparing surgical and non-surgical management — M. Baud, A. Bobbio, et al. (2014)
• Extensive surgical resections for rare pleural neoplasms: a single-center experience with a yolk sac tumor and synovial sarcoma — T. Vandaele, J. Van Slambrouck, et al. (2024)
• Surgical Options for Malignant Mesothelioma: A Single-Center Experience — S.R. Kang, J.S. Bok, et al. (2018)
• Surgical Diagnosis of Malignant Pleural Mesothelioma: 20 Years' Experience at a High-Volume Referral Center — A. Iaffaldano, T. Charrier, et al. (2021)
• Surgical management of retrorectal tumors: a retrospective study of a 9-year experience in a single institution — C. Lin, K. Jin, et al. (2011)
• Evolution of locoregional treatment for peritoneal carcinomatosis: single-center experience of 308 procedures of cytoreductive surgery and perioperative intraperitoneal chemotherapy — T.C. Chua, W. Liauw, et al. (2011)

Browse more research in Journal of Clinical Medicine, or return to medical research.