Elsevier

Lung Cancer

Volume 81, Issue 3, September 2013, Pages 319-327
Lung Cancer

Systematic review of pleurectomy in the treatment of malignant pleural mesothelioma

https://doi.org/10.1016/j.lungcan.2013.04.024Get rights and content

Abstract

Introduction

Pleurectomy/decortication (P/D) in the treatment of malignant pleural mesothelioma includes a number of procedures with different clinical indications and therapeutic intents. To unify the nomenclature, IMIG and IASLC recently defined P/D-related procedures according to surgical technique, including ‘extended P/D’, ‘P/D’ and ‘partial pleurectomy’. The present systematic review aimed to assess the safety and efficacy of these techniques.

Methods

A systematic review of relevant studies was performed by electronic search of five online databases from 1985 to 2012 by two independent reviewers according to predefined selection criteria.

Results

Thirty-four studies involving 1916 patients who underwent pleurectomy were included for quantitative analysis. These included 12 studies on ‘extended P/D’, 8 studies on ‘P/D’ and 14 studies on ‘partial pleurectomy’. Perioperative mortality ranged from 0% to 11% and perioperative morbidity ranged from 13% to 43%. Median overall survival ranged from 7.1 to 31.7 months and disease-free survival ranged from 6 to 16 months. One study reported on quality-of-life outcomes using a standardized questionnaire suggesting superior outcomes for ‘extended P/D’ compared to extrapleural pneumonectomy.

Conclusions

Results of the present systematic review suggested similar perioperative mortality outcomes between different P/D techniques but a trend towards higher morbidity and length of hospitalization for patients who underwent ‘extended P/D’. However, overall and disease-free survival appeared to favour ‘extended P/D’ compared to less aggressive techniques. Future studies on P/D should adhere to recent definitions to enable accurate analysis of similar procedures. Direct comparisons of pleurectomy to extrapleural pneumonectomy remain challenging, and should be restricted to ‘extended P/D’ procedures only.

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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