Systematic Review and Meta-Analysis of Pleurectomy/Decortication versus Extrapleural Pneumonectomy in the Treatment of Malignant Pleural Mesothelioma

Our plain-English summary of Systematic Review and Meta-Analysis of Pleurectomy/Decortication versus Extrapleural Pneumonectomy in the Treatment of Malignant Pleural Mesothelioma, by F. Danuzzo, S. Maiorca, G. Bonitta, et al (Journal of Clinical Medicine, 2022).

The study

• Authors: F. Danuzzo, S. Maiorca, G. Bonitta, M. Nosotti
• Journal: Journal of Clinical Medicine
• Published: 2022;11(19)
• Type of article: Review
• Cited by: 12 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Objective: Malignant pleural mesothelioma (MPM) is a rare and aggressive malignant cancer for which there are poor treatment options. Extrapleural pneumonectomy (EPP) and pleurectomy decortication (P/D) are the two most used surgical procedures in patients with resectable disease. We reviewed the available literature in order to compare the overall survival and postoperative complications of EPP and P/D and to provide evidence for the best procedure in the treatment of MPM. Methods: We performed a systematic review of the literature, including studies from August 2018 to May 2022. The primary outcome was 5-year overall survival (OS) and the secondary outcomes were 30-day mortality, 90-day mortality and peri-operative complications. Results: Thirteen studies were considered, including a total of 1624 patients treated with EPP and 2147 treated with P/D. The estimated pooled HR showed a significant lower hazard for P/D compared to EPP in terms of OS (HR = 0.76; 95% CI from 0.62 to 0.94; p < 0.001). In 12 studies, the risk for 30-day mortality was lower for patients treated with P/D (RR = 0.49; 95% CI from 0.31 to 0.76; p = <0.01), whereas only five studies reported 90-day mortality, and no statistically significant difference between EPP and P/D was found (RR = 0.71; 95% CI from 0.47 to 1.07; p = 0.10). The OS restricted mean survival time difference meta-analysis (RMSDT) confirms the superior survival of P/D on the EPP, a superiority that increases from 0.54 months at one year to 4.23 at five years. The incidence of postoperative empyema, atrial fibrillation, bleeding and bronchopleural fistula was significantly increased in the EPP group except for prolonged air leakage, which is only characteristic of P/D. Conclusions: Using two different statistical methods, this meta-analysis suggests that long-term survival after surgical treatment for resectable MPM is greater for patients undergoing P/D. Long-term survival had never been previously analyzed with appropriate tests; on the contrary, our result is consistent with the previous meta-analyses and reinforces the evidence of lower 30-day mortality and the prevalence of postoperative complications in P/D versus EPP patients. The recent introduction of innovative therapeutic schemes, both adjuvant and neoadjuvant therapy, keeps the discussion on surgical strategy open and will require new studies.

In plain English

This systematic review and meta-analysis pooled 13 studies from seven countries, published 2003 to 2022 (one prospective, 12 retrospective). All compared two operations for malignant pleural mesothelioma: pleurectomy/decortication (P/D), removing the pleura, and extrapleural pneumonectomy (EPP), also removing the affected lung. 2147 patients had P/D or extended P/D and 1624 had EPP. P/D patients had a lower risk of death over follow-up (hazard ratio 0.76; 95% CI 0.62 to 0.94). A second method put P/D's average survival gain at 0.54 months within one year (95% CI 0.03 to 1.05; 13 studies) and 4.23 months within five years (95% CI 1.0 to 7.46; nine studies). Death within 30 days was lower with P/D (risk ratio 0.49; 95% CI 0.31 to 0.76; 12 studies). Death within 90 days did not differ significantly, but only five studies reported it. Complications were less common after P/D, though prolonged air leaks occurred only after P/D. The authors concluded P/D gave a limited but significant survival benefit. They cautioned that most studies were retrospective and publication bias could not be excluded.

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 published studies (13 included: 1 prospective, 12 retrospective, 2 of which used propensity score matching)
• Who was studied: 3771 patients with malignant pleural mesothelioma in 13 studies from the UK, Italy, South Africa, the USA, Switzerland, Japan and Singapore, published 2003 to 2022; 2147 treated with P/D or extended P/D and 1624 with EPP
• Exposure: Not an asbestos exposure study. The comparison was between two surgical procedures for resectable malignant pleural mesothelioma: pleurectomy/decortication (including extended P/D) versus extrapleural pneumonectomy, with EPP as the reference group
• Main results:
  • Overall survival: pooled hazard ratio of 0.76 for P/D compared with EPP (95% CI 0.62 to 0.94; p < 0.001), from 13 studies and 3771 patients
  • Heterogeneity between studies for overall survival was I2 = 74.3%, which the authors described as moderate
  • Restricted mean survival time difference favored P/D at each time horizon: 0.54 months at 12 months (95% CI 0.03 to 1.05; 13 studies) and 4.23 months at 60 months (95% CI 1.0 to 7.46; 9 studies). Only nine studies had 5 years of follow-up
  • Studies contributing to the restricted mean survival time analysis: all 13 had at least 3 years of follow-up, 12 had 4 years and 9 had 5 years
  • The 60-month restricted mean survival time difference for P/D versus EPP was 4.23 months (95% CI 1.0 to 7.46; p = 0.01)
  • 30-day mortality was lower for P/D patients: risk ratio 0.49 (95% CI 0.31 to 0.76), based on 12 studies
  • 90-day mortality showed no statistically significant difference between EPP and P/D: risk ratio 0.71 (95% CI 0.47 to 1.07; p = 0.10), based on only five studies
  • Total postoperative complications (10 trials) were significantly lower after P/D: risk ratio 0.64 (95% CI 0.45 to 0.90)
  • Compared with EPP, P/D had lower risk of postoperative empyema (RR 0.12), atrial fibrillation (RR 0.39) and hemorrhage (RR 0.35)
  • Prolonged air leaks occurred only in the P/D group, with a pooled prevalence of 0.20
  • No significant differences between the procedures for myocardial infarction (RR 1.19) or pulmonary embolism (RR 0.51)
• The authors' conclusion: The authors concluded that their analysis showed a limited but significant long-term survival benefit for P/D. They also concluded it reinforced evidence of lower 30-day mortality and fewer postoperative complications with P/D than with EPP
• Limitations the authors state:
  • Most included studies were retrospective and observational. Surgeons chose between P/D and EPP on clinical grounds, which may have introduced selection bias
  • Clinical follow-up probably differed between centers, which may have biased survival results and how complications were categorized
  • Publication bias was noted for the main survival result
  • The proportional hazards assumption was violated in two studies, so the authors urged caution about the hazard ratio
  • The analysis combined P/D and extended P/D, which different surgical groups may have performed with different protocols
  • Neoadjuvant and adjuvant treatments varied widely between patients and were not analyzed

Topics

Medical terms in this study, explained in our Lexicon: Systematic Review, Meta-Analysis, Pleurectomy/Decortication (P/D), Extrapleural Pneumonectomy (EPP), Pleural Mesothelioma, Overall Survival, Empyema, Neoadjuvant Therapy.

Related studies

• 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)
• Current Treatment of Mesothelioma: Extrapleural Pneumonectomy Versus Pleurectomy/Decortication — A.S. Wolf, R.M. Flores (2016)
• Extrapleural Pneumonectomy Versus Pleurectomy/Decortication for Malignant Pleural Mesothelioma — N. Zhou, D.C. Rice, et al. (2022)
• 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)

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