Surgical indications for pleurectomy/decortication in pleural mesothelioma based on the newly revised 9th edition of the tumour-node-metastasis classification

Our plain-English summary of Surgical indications for pleurectomy/decortication in pleural mesothelioma based on the newly revised 9th edition of the tumour-node-metastasis classification, by M. Kanayama, M. Takenaka, T. Manabe, et al (Interdisciplinary Cardiovascular and Thoracic Surgery, 2024).

The study

• Authors: M. Kanayama, M. Takenaka, T. Manabe, K. Yoshimatsu, R. Oyama, H. Matsumiya, M. Mori, K. Kuroda, F. Tanaka
• Journal: Interdisciplinary Cardiovascular and Thoracic Surgery
• Published: 2024;40(1)
• Cited by: 3 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Objectives: The MARS2 trial questioned the efficacy of curative intent surgery for pleural mesothelioma (PM), while real-world clinical data from Japan suggest a favourable prognosis in surgical cases, indicating survival benefits in selected patients. The newly revised 9th edition of the tumour-node-metastasis (TNM) classification introduces a novel indicator based on pleural thickness.

Methods: We conducted a retrospective evaluation of patients with PM who underwent pleurectomy/decortication between 2012 and 2022. Patient characteristics, complications and treatment outcomes were assessed. Additionally, outcomes were analysed based on the 9th edition of the TNM classification.

Results: A total of 62 patients were included in the analysis. The median overall survival (OS) was 37.3 months, with a median relapse-free survival (RFS) of 15.5 months. Patients with the epithelioid subtype (OS: 61.6 months; RFS: 26.0 months) and pStage IA (OS: not reached; RFS: 69.1 months) had significantly better outcomes. The 9th edition of the TNM classification showed a stronger prognostic correlation than the 8th edition, with a median OS of 77.0, 31.9, 20.4 and 25.3 months for stages I, II, IIIA and IIIB (P = 0.0016) and median RFS of 34.3, 12.3, 13.7 and 6.9 months for stages I, II, IIIA and IIIB (P = 0.013), respectively.

Conclusions: Surgical intervention remains crucial in the treatment of PM, particularly for patients with epithelioid histology and early stages of the disease. This study evaluates surgical indications for PM using the newly revised 9th edition of the TNM classification, indicating that it enhances the precision of surgical candidate selection and potentially improves patient outcomes.

© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.

In plain English

This retrospective study from one Japanese surgical department reviewed 62 patients with pleural mesothelioma who had pleurectomy/decortication between 2012 and 2022. Asbestos exposure is not discussed. Median overall survival after surgery was 37.3 months (95% CI 27.3 to 47.3) and median relapse-free survival 15.5 months (95% CI 12.2 to 18.8); 43 patients (69.4%) relapsed. No patient died within 30 days of surgery and one within 90 days, though 75.8% (47/62) had complications. Median overall survival was 61.6 months (95% CI 27.4 to 95.8) for epithelioid, 31.9 months (95% CI 22.7 to 41.1) for biphasic and 15.9 months (95% CI 11.7 to 20.1) for sarcomatoid tumours. The authors also applied the new 9th edition TNM staging, which adds pleural thickness measurements. Its 20 stage I patients had median survival of 77.0 months (95% CI 47.8 to 106.2), and the authors reported a stronger stage-survival link than with the 8th edition. The authors concluded that selection by tumour type and staging matters, and that definitive survival benefits need further research. They noted the single-centre design, changing treatment over time, and no non-surgical comparison.

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 cohort study of surgically treated patients
• Who was studied: 62 patients with pleural mesothelioma who underwent pleurectomy/decortication at the University of Occupational and Environmental Health, Kitakyushu, Japan, between January 2012 and December 2022. Of 67 operated patients, 5 who had salvage surgery after immune checkpoint inhibitor treatment were excluded. There were 56 men and 6 women, with a median age of 69. By tumour type, 46 were epithelioid, 6 biphasic and 10 sarcomatoid.
• Exposure: Not reported. The article does not describe asbestos fiber types, jobs or doses. What the study examined was surgery (pleurectomy/decortication, extended in 55 cases) and staging by the 8th and 9th editions of the TNM classification.
• Main results:
  • For all 62 patients, median overall survival was 37.3 months (95% CI 27.3 to 47.3) and median relapse-free survival was 15.5 months (95% CI 12.2 to 18.8).
  • Relapse occurred in 43 patients (69.4%). Of these, 34 (79.1%) had loco-regional relapse and 9 (20.9%) had both loco-regional and distant relapse. 28 patients (45.2%) died during follow-up, and the median follow-up was 28.5 months.
  • Macroscopic complete resection was achieved in 91.9% (57/62). Postoperative complications occurred in 75.8% (47/62), or 43.5% (27/62) when prolonged air leaks were excluded.
  • There were no deaths within 30 days after surgery and one death within 90 days.
  • Median overall survival by tumour type was 61.6 months (95% CI 27.4 to 95.8) for epithelioid, 31.9 months (95% CI 22.7 to 41.1) for biphasic and 15.9 months (95% CI 11.7 to 20.1) for sarcomatoid. Median relapse-free survival was 26.0, 11.8 and 4.0 months respectively. Outcomes were significantly better for epithelioid than non-epithelioid types (overall survival P = 0.0016; relapse-free survival P less than 0.001).
  • By pathological stage (8th edition), pStage IA had median overall survival not reached and median relapse-free survival of 69.1 months. Outcomes were better for pStage IA than for pStage IB and beyond (overall survival P = 0.014; relapse-free survival P = 0.035).
  • By clinical stage (8th edition), outcomes trended better for cStage IA than for cStage IB and beyond, but this was not statistically significant (overall survival P = 0.070; relapse-free survival P = 0.058).
  • By the 9th edition clinical stage, median overall survival was 77.0 months (95% CI 47.8 to 106.2) for stage I (20 patients), 31.9 months for stage II (22), 20.4 months for stage IIIA (19) and 25.3 months for stage IIIB (1). Median relapse-free survival was 34.3, 12.3, 13.7 and 6.9 months (P = 0.0016 for overall survival and P = 0.013 for relapse-free survival). The authors stated this showed a stronger correlation with prognosis than the 8th edition.
  • In multivariable analysis, 9th edition clinical stage I (vs. II and beyond) was an independent prognostic factor for overall survival (HR 0.268, 95% CI 0.104 to 0.687), as was postoperative adjuvant therapy (HR 0.359, 95% CI 0.160 to 0.803). For relapse-free survival, the independent factors were clinical stage (HR 0.464), adjuvant therapy (HR 0.450) and histological type (HR 0.356).
  • The area under the curve for the 9th edition staging was 0.763 (95% CI 0.644 to 0.882) for overall survival and 0.622 (95% CI 0.477 to 0.768) for relapse-free survival.
• The authors' conclusion: The authors concluded that their retrospective study gives insight into the potential role of surgery for resectable pleural mesothelioma, but that further research is necessary to establish definitive survival benefits. They emphasized careful patient selection by histological subtype and staging with the revised 9th edition TNM classification, which they said aims to make the selection of surgical candidates more precise.
• Limitations the authors state:
  • The study was a retrospective cohort from a single institution, which the authors said does not adequately reflect the general population with this disease.
  • Diagnostic and treatment approaches changed substantially over 2012 to 2022, so treatment strategies varied across the cohort.
  • The findings were not compared with patients who did not have surgery.

Topics

Medical terms in this study, explained in our Lexicon: Pleurectomy/Decortication (P/D), Pleural Mesothelioma, Metastasis, Prognosis, Pleural Thickening, TNM Staging, Median Overall Survival, Epithelioid.

Related studies

• External validation of pathological T adjustments in the ninth edition of the pleural mesothelioma tumor-node-metastasis classification — Z. Liu, J. Cai, et al. (2025)
• Non-incisional pleurectomy/decortication for malignant pleural mesothelioma — F. Tanaka, M. Takenaka, et al. (2021)
• Salvage pleurectomy/decortication following immunotherapy for malignant pleural mesothelioma — M. Takenaka, K. Kuroda, et al. (2024)
• Pleurectomy decortication is the preferred surgical procedure in pleural mesothelioma — M. Lapidot, R. Bueno (2023)
• Is it time to consider pleurectomy and decortication as the only surgical treatment for malignant pleural mesothelioma? — M.J. Weyant (2012)
• 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)

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