The evolution of the diminishing role of extrapleural pneumonectomy in the surgical management of malignant pleural mesothelioma

Our plain-English summary of The evolution of the diminishing role of extrapleural pneumonectomy in the surgical management of malignant pleural mesothelioma, by A.G. Azzouqa, J.P. Stevenson (OncoTargets and Therapy, 2016).

The study

• Authors: A.G. Azzouqa, J.P. Stevenson
• Journal: OncoTargets and Therapy
• Published: 2016;9:7247-7252
• Type of article: Review
• Cited by: 3 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant pleural mesothelioma is an uncommon and aggressive thoracic malignancy that is rarely curable, even when multimodality therapy is used. Systemic chemotherapy is the primary treatment for the majority of patients with this disease; however, surgical resection may benefit a subset of patients with early-stage disease. The surgical approach that offers the best outcomes remains an area of controversy, with data from retrospective comparisons being the only guide. Historically, extrapleural pneumonectomy (EPP) has been the standard procedure, carrying with it a cost of significant morbidity and impact on quality of life that has raised questions regarding its routine application. Over the past two decades as surgical techniques have been refined and survival data with EPP in large case series have been reported, the paradigm has evolved toward the use of lung-sparing pleural resections such as pleurectomy/decortication (P/D) and extended P/D. The identification of patients who may benefit from EPP over pleurectomy has proven problematic, and the larger question regarding the impact of any type of surgical intervention on outcomes for pleural mesothelioma patients is still an area of investigation. Uniform treatment approaches have been difficult to develop due to the relatively small numbers of patients with this disease, the use of a staging system that does not readily identify those who may benefit from more aggressive therapy, and the institutional biases that have resulted from the growth of multimodality centers of excellence.

In plain English

This article was a review, not a new study. The authors looked at published reports on surgery for malignant pleural mesothelioma. They compared extrapleural pneumonectomy (EPP), which removes the lung, pleura, pericardium and same-side diaphragm, with lung-sparing pleurectomy/decortication (P/D) and extended P/D. The review did not study asbestos exposure. A reviewed 2008 series of 663 patients at three US centers reported median survival of 16 months after P/D versus 12 months after EPP. In a small UK feasibility trial (MARS), median survival was 14.4 months with EPP and 19.5 months without it, but the trial was too small to analyze survival as a main outcome. An international database found longer survival with EPP than with P/D only among 132 stage I patients. The authors summarized that P/D and extended P/D had better outcomes around the time of surgery, with no clear difference in survival. They concluded that repeated analyses of historical data do not show a benefit of EPP over P/D or extended P/D. They noted that the evidence lacks prospective comparisons and is shaped by institutional bias.

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: Narrative review of published surgical series, trials, database analyses and meta-analyses
• Who was studied: No new patients. The review covered published studies of patients with malignant pleural mesothelioma treated with surgery.
• Exposure: No asbestos exposure was studied; asbestos is mentioned only in the background. The review compared surgical procedures: EPP (en bloc removal of the visceral and parietal pleura, pericardium, ipsilateral hemidiaphragm and lung) versus lung-sparing P/D and extended P/D.
• Main results:
  • In a reviewed 2008 retrospective series (Flores et al) of 663 consecutive patients at three US academic centers, median survival was 16 months for P/D versus 12 months for EPP.
  • In the reviewed MARS feasibility trial (UK), median survival after induction chemotherapy was 14.4 months in the EPP group and 19.5 months in the non-EPP group. Fifty patients were randomized: 24 to EPP and 26 to non-surgical care. The sample size was insufficient to analyze outcome as the primary end point.
  • In the reviewed 2012 IASLC database (3,101 patients), stage I patients (132 in total) resected by EPP had a median survival of 40 months, compared with 23 months for those resected by P/D. There was no difference in survival at later stages.
  • In a reviewed single-institution prospective experience (Lang-Lazdunski et al), median overall survival was 23 months for extended P/D versus 12.8 months for EPP.
  • In a reviewed meta-analysis (Taioli et al), 2-year mortality was 25% for P/D vs 23.8% for EPP (P=0.08). The authors reported this as not significantly different.
  • The authors' synthesis of the two meta-analyses was that P/D and extended P/D had better outcomes around the time of surgery than EPP, with no clear differences in survival.
• The authors' conclusion: The authors concluded that repeated analyses of historical data do not show a benefit of EPP over P/D or extended P/D. They also concluded that EPP should one day be of historical interest only, with rare exceptions.
• Limitations the authors state:
  • The authors stated that the evidence base lacks prospective comparative analyses.
  • The authors stated that institutional bias and practice influence the surgical approaches used and reported.

Topics

Medical terms in this study, explained in our Lexicon: Extrapleural Pneumonectomy (EPP), Pleural Mesothelioma, Multimodal Therapy, Chemotherapy, Surgical Resection, Quality of Life, Pleurectomy/Decortication (P/D), Staging.

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)
• Impact of induction therapy on postoperative outcome after extrapleural pneumonectomy for malignant pleural mesothelioma: does induction-accelerated hemithoracic radiation increase the surgical risk? — P. Mordant, K. McRae, et al. (2016)
• 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)
• 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)
• Quantitation and predictors of short-term mortality following extrapleural pneumonectomy, pleurectomy/decortication, and nonoperative management for malignant pleural mesothelioma — C. Wright, V. Verma, et al. (2020)
• Photodynamic therapy and the evolution of a lung-sparing surgical treatment for mesothelioma — J.S. Friedberg, R. Mick, et al. (2011)

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