Systematic review of pleurectomy in the treatment of malignant pleural mesothelioma
Introduction
Therapeutic surgical treatment of malignant pleural mesothelioma (MPM) includes extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D), both of which can be incorporated into multimodality regimens involving neoadjuvant or adjuvant chemotherapy and adjuvant radiotherapy [1]. EPP is a form of cytoreductive surgery that aims to remove all visible tumour from patients who are deemed to have resectable disease, and involves en bloc resection of the pleurae, lung, ipsilateral hemidiaphragm, and ipsilateral pericardium, as originally described by Butchart in 1976 [2], [3], [4]. The definition of pleurectomy, on the other hand, has been variable in regards to surgical technique, therapeutic intent and clinical indication.
To clarify and unify the definition of P/D, the International Mesothelioma Interest Group (IMIG), in collaboration with the International Association for the Study of Lung Cancer (IASLC), recently published a Consensus Report that classified pleurectomy-related procedures into three well-defined categories according to surgical technique, including ‘extended P/D’, ‘P/D’ and ‘partial pleurectomy’ [5]. This will enable future registries and studies to compare similar surgical procedures using a standardized nomenclature. The aim of the present systematic review was to apply the new IMIG and IASLC definitions to previous studies on P/D and to compare the safety and efficacy of these procedures in the treatment of MPM. Primary endpoints included perioperative mortality and long-term survival. Secondary endpoints included perioperative morbidity, disease-free survival and quality-of-life outcomes.
Section snippets
Literature search strategy
Electronic searches were conducted using Ovid Medline, Cochrane Central Register of Controlled Trials (CCTR), Cochrane Database of Systematic Reviews (CDSR), ACP Journal Club, and Database of Abstracts of Review of Effectiveness (DARE) from January 1985 to 1 November 2012. To achieve maximum sensitivity, we combined either ‘pleurectomy’ or ‘decortication’ with ‘mesothelioma’ as either keywords or MeSH terms. The reference lists of all retrieved articles were reviewed for further identification
Quantity of trials
Electronic search of 5 online databases identified 170 potentially relevant articles and 11 additional articles were retrieved from other sources. After initial screening of 181 articles according to titles and abstracts, 86 studies were selected for full-text review. After applying the predefined selection criteria, 43 articles remained for quantitative assessment. Of these, 9 studies were deemed to present duplicating data. A summary of the search strategy is presented as supplementary
Discussion
Pleurectomy in the treatment of MPM was first described by Martini and colleagues in 1975 in a series of 14 patients who underwent debulking of pleural tumour followed by external radiation and systemic chemotherapy [40]. Since then, a number of non-randomized studies have demonstrated the feasibility of pleurectomy for MPM. However, it has been evident that P/D procedures differ between institutions in terms of therapeutic intent and surgical technique. Less invasive pleurectomy procedures
Conclusions
In conclusion, pleurectomy procedures can be performed safely for patients with MPM, but vary greatly in terms of surgical technique and clinical intent. Evidence from the existing literature suggests that selected patients who undergo extended P/D may achieve a longer overall and disease-free survival compared to patients who undergo less aggressive procedures such as P/D or partial pleurectomy. However, this may be associated with higher morbidity and longer hospitalization. Perioperative and
Conflict of interest
No potential conflict of interest.
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Cited by (44)
Neoadjuvant pemetrexed plus cisplatin followed by pleurectomy for malignant pleural mesothelioma
2022, Journal of Thoracic and Cardiovascular SurgeryLymphangitic carcinomatosis: A common radiographic manifestation of local failure following extended pleurectomy/decortication in patients with malignant pleural mesothelioma
2019, Lung CancerCitation Excerpt :Given the potential for increased risk of retained microscopic residual disease in EPD [12] compared to EPP, at our institution, most patients also receive intraoperative pleural photodynamic therapy (PDT) with the goal of eradicating residual microscopic disease [13]. With all therapy for MPM, the failure rate is high and an improved understanding of the predictive and prognostic implications of radiologic findings is important for disease management and prognostication [14]. In this retrospective study, we sought to characterize the incidence and prognostic significance of the appearance of the radiographic pattern of LC in MPM patients who have undergone EPD.
Surgery in Malignant Pleural Mesothelioma
2018, Journal of Thoracic OncologyCitation Excerpt :Mirroring results from EPP series, epithelioid histology and early-stage disease remain significant predictors of survival in patients undergoing P/D / (e)P/D.38,42 In mixed cohorts of patients undergoing EPP or P/D / (e)P/D, epithelial histology, early-stage disease, as well as nodal status continue to predict survival in the setting of multimodality treatment reiterating the importance of preoperative mediastinoscopy and radiographic staging regardless of surgical procedure performed.38,43 In a systematic review of P/D / (e)P/D, Cao et al.44 report overall perioperative morbidity of 13% to 48%.44 Visceral pleurectomy often involves injury to the underlying lung parenchyma resulting in bleeding and air leak.
Survival by Histologic Subtype of Malignant Pleural Mesothelioma and the Impact of Surgical Resection on Overall Survival
2018, Clinical Lung CancerCitation Excerpt :These methods are likely a prime cause of the discrepant results regarding surgery for sarcomatoid disease between this and the other investigation. Additionally, we opted to include both extrapleural pneumonectomy and pleurectomy/decortication as a singular category as the comparator of GMR, given that both have been utilized for management despite a lack of comparative randomized data.5,10,36-44 In the absence of comparative phase 3 trials, this issue is likely to remain unresolved in the near future, and thus both options are considered feasible and viable options per national guidelines.9
Diaphragm and lung–preserving surgery with hyperthermic chemotherapy for malignant pleural mesothelioma: A 10-year experience
2018, Journal of Thoracic and Cardiovascular SurgeryCitation Excerpt :Postoperative mortality and morbidity are serious drawbacks of EPP and EPD. In fact, these operations are burdened with a relatively high mortality: a recent meta-analysis found a mortality rate ranging from 3.7% to 7.6% for EPP31 and 4% for EPD or P/D32; moreover, the major complication rate was almost 50% in EPP and up to 43% in EPD-P/D.33 In our experience, no case of mortality was observed in the first 90 days from surgery, and our complication rate was 46.9%, comparable with other experiences. In particular, among the 22 patients who experienced complications, only 14 had a severe complication (classified as stage 3 according to Common Terminology Criteria for Adverse Events, version 4.03; no stage 4 complications were registered).
Is less also better? A single-institution experience on treatment of early stage Malignant Pleural Mesothelioma
2017, European Journal of Surgical OncologyCitation Excerpt :The role of chemotherapy associated with surgery is not fully cleared.2,31 Many authors reported chemotherapy used in an induction or adjuvant setting both for EPP and P/D16,18,28,32; in any case, favorable outcomes might be biased by the selection made by induction treatments or by the fact that only the fittest patients can undergo an adjuvant chemo after surgery. In a retrospective study, Sugarbaker and his colleagues19 found that adjuvant chemotherapy after surgery and HITHOC was an independent factor for better prognosis; our protocol provided for three cycles of adjuvant chemotherapy and all our patients eventually conclude the planned treatment, with no additional toxicity.