VATS Pleurectomy Decortication Is a Reasonable Alternative for Higher Risk Patients in the Management of Malignant Pleural Mesothelioma: An Analysis of Short-Term Outcomes

Our plain-English summary of VATS Pleurectomy Decortication Is a Reasonable Alternative for Higher Risk Patients in the Management of Malignant Pleural Mesothelioma: An Analysis of Short-Term Outcomes, by D.S. Lee, A. Carollo, N. Alpert, et al (Cancers, 2021).

The study

• Authors: D.S. Lee, A. Carollo, N. Alpert, E. Taioli, R. Flores
• Journal: Cancers
• Published: 2021;13(5)
• Cited by: 4 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Surgery is a mainstay of treatment allowing for debulking of tumor and expansion of the lung for improvement in median survival and quality of life for patients with malignant pleural mesothelioma (MPM). Although optimal surgical technique remains open for debate-extrapleural pneumonectomy (EPP) vs. pleurectomy/decortication (P/D)-minimally invasive surgery (VATS-P/D) remains underutilized in the management of MPM. We examined whether VATS-P/D is a feasible alternative to EPP and P/D. We evaluated the New York Statewide Planning and Research Cooperative System (SPARCS) from 2007-2017 to assess the short-term complications of EPP vs. P/D, including a subanalysis of open P/D vs. VATS-P/D. There were 331 patients with open surgery; 269 with P/D and 62 with EPP. There were 384 patients with P/D; 269 were open and 115 VATS. Rates of any complication were similar between EPP and P/D patients, but EPP had significantly higher rates of cardiovascular complications. After adjusting for confounders, those with a VATS approach were less likely to have any complication, compared to an open approach and significantly less likely to have a pulmonary complication. VATS-P/D remains a viable alternative to radical surgery in MPM patients allowing for improved short-term outcomes.

In plain English

This study used New York State hospital discharge records (SPARCS) from 2007 to 2017 to compare short-term in-hospital complications after surgery for malignant pleural mesothelioma. Of 331 patients who had open surgery, 269 had lung-sparing pleurectomy/decortication (P/D) and 62 had extrapleural pneumonectomy (EPP). Rates of any complication were similar (43.5% for EPP vs 42.0% for P/D), but EPP patients had more cardiovascular complications (32.3% vs 13.4%). After adjustment, EPP was associated with higher odds of any complication (odds ratio 2.12, 95% CI 1.08 to 4.18). In a smaller matched analysis, this difference was not statistically significant. Among 384 P/D patients, 115 had minimally invasive (VATS) surgery and 269 had open surgery. The VATS patients were older and were more often admitted urgently. After adjustment, VATS was associated with lower odds of pulmonary complications (0.55, 95% CI 0.31 to 0.99). The lower odds of any complication (0.58, 95% CI 0.34 to 1.01) were not statistically significant, and neither were the matched results. The authors concluded that VATS P/D should be considered, especially for older, frailer patients. They noted small numbers, possible selection bias and no data on tumor stage.

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 analysis of a statewide hospital discharge database (New York SPARCS), comparing types of surgery and surgical approaches, using multivariable logistic regression and propensity matching
• Who was studied: Patients at least 50 years old who were discharged from New York State hospitals between 1 January 2007 and 31 December 2017 with a diagnosis of pleural mesothelioma and who had EPP or P/D (n = 589). Exclusions (n = 143) left 331 patients with open EPP or P/D for the first analysis and 384 P/D patients (269 open, 115 minimally invasive) for the second analysis
• Exposure: The study compared types of surgery (extrapleural pneumonectomy vs pleurectomy/decortication) and surgical approaches (minimally invasive/VATS vs open P/D). Asbestos exposure was not studied.
• Main results:
  • Open surgery patients, unadjusted: any complication occurred in 43.5% of EPP patients (27/62) and 42.0% of P/D patients (113/269), p = 0.8248
  • Open surgery patients, unadjusted: cardiovascular complications were more common with EPP (32.3%) than with P/D (13.4%), p = 0.0004. Pulmonary complications were less common with EPP (21.0%) than with P/D (34.2%), p = 0.0439
  • Multivariable analysis (n = 326), EPP vs P/D: any complication ORadj 2.12 (95% CI 1.08 to 4.18); cardiovascular complication ORadj 5.00 (95% CI 2.23 to 11.24); supraventricular arrhythmia ORadj 6.63 (95% CI 2.64 to 16.64); pulmonary complication ORadj 0.89 (95% CI 0.41 to 1.91), not significant
  • Propensity-matched analysis (50 EPP vs 50 P/D patients): no difference was statistically significant. Any complication OR 1.11 (95% CI 0.45 to 2.73); cardiovascular OR 2.60 (95% CI 0.93 to 7.29); supraventricular arrhythmia OR 2.75 (95% CI 0.88 to 8.64)
  • Among P/D patients, those with minimally invasive surgery were older (mean 71.8 vs 69.1 years, p = 0.0132) and more likely to have an urgent/emergency admission (adjusted ORadj 7.18, 95% CI 4.07 to 12.64) than those with open surgery
  • Multivariable analysis (n = 378), minimally invasive vs open P/D: pulmonary complication ORadj 0.55 (95% CI 0.31 to 0.99; p = 0.0448). Any complication ORadj 0.58 (95% CI 0.34 to 1.01; p = 0.0524), not statistically significant. Cardiovascular complication ORadj 0.88 (95% CI 0.40 to 1.95)
  • Propensity-matched analysis (75 patients per group), minimally invasive vs open P/D: results were not statistically significant. Any complication OR 0.70 (95% CI 0.37 to 1.32); pulmonary complications OR 0.65 (95% CI 0.30 to 1.38)
• The authors' conclusion: The authors concluded that patients undergoing VATS P/D had better short-term outcomes, and that VATS P/D should be considered among treatments for MPM, especially in older and frailer patients who may not tolerate more radical surgery
• Limitations the authors state:
  • Mesothelioma is uncommon, so patient numbers were relatively small despite the large database
  • There may be selection bias in which surgical technique patients received, due to surgeon preference and elective versus emergent presentation
  • The database lacked information on tumor grade, oncologic stage, long-term outcomes, surgeon experience and induction therapy, so these confounders could not be addressed
  • Perioperative mortality was not analyzed because there were too few observations
  • Infectious and intraoperative complications were too few to be assessed beyond the univariate level

Topics

Medical terms in this study, explained in our Lexicon: Video-Assisted Thoracoscopic Surgery (VATS), Pleural Mesothelioma, Median Overall Survival, Quality of Life, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D).

Related studies

• Short-term outcomes of pleurectomy decortication and extrapleural pneumonectomy in mesothelioma — M. van Gerwen, A. Wolf, et al. (2018)
• 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)
• Comparison of video-assisted pleurectomy/decortication surgery plus hyperthermic intrathoracic chemotherapy with VATS talc pleurodesis for the treatment of malignant pleural mesothelioma: A pilot study — M. Migliore, M. Fiore, et al. (2023)
• Short-Term Outcomes of COVID-19 Pandemic on Non-Small Cell Lung Cancer Screening and Management — F. Orelaru, M. Edwards, et al. (2023)
• 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)
• Clinical Outcomes With Recurrence After Pleurectomy/Decortication for Malignant Pleural Mesothelioma — A. Nakamura, T. Takuwa, et al. (2020)

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