The use of extended pleurectomy decortication as a surgical approach in the treatment of patients with malignant pleural mesothelioma (MPM) was associated with a low risk of postoperative mortality, and prolonged OS in those achieving a macroscopic complete resection (MCR) with this procedure, according to findings from a retrospective chart review reported in Annals of Surgery.

Malignant pleural mesothelioma (MPM) is an aggressive malignancy of the lung pleura which line the surface of the lungs; it is predominantly caused by prior exposure to asbestos. 

The National Comprehensive Cancer Network (NCCN) guidelines on the diagnosis and treatment of MPM include recommendations for the use of multimodality treatment, including achievement of surgical MCR, and the use of systemic approaches to address metastatic disease, to optimize the management of patients with this disease.2

Extrapleural pneumonectomy for the treatment of MPM involves removal of a lung, and sections of the parietal pleura, pericardium, and diaphragm. An alternative surgical procedure, pleurectomy decortication, a form of lung-sparing surgery, involves removal of the parietal and visceral pleura and visible tumor masses. Extended pleuroectomy decortication also includes surgical removal of the pericardium and ipsilateral diaphragm.


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Although there is evidence that pleurectomy decortication/extended pleurectomy decortication is being increasingly preferred over extrapleural pneumonectomy for the surgical treatment of patients with MPM, the aim of this study was to evaluate the short- and long-term outcomes, as well as associated prognostic factors, of patients undergoing the pleurectomy decortication type of procedure for the surgical treatment of MPM.

This analysis was based on data abstracted from the medical records of 355 consecutive patients with MPM who underwent thoracotomy for planned pleurectomy decortication at a single institution between 2007 and 2015.

The most common postoperative complications were low grade, and included prolonged air leak (46.5%), deep venous thrombosis (21.1%), atrial fibrillation (13.9%), Chyle leak (7.9%), empyema (7.6%), and pneumonia (6.9%). Thirty- and 90-day mortality were 3%, and 4.6%, respectively, for these patients.

A comparison of patients who achieved MCR vs those who did not showed median overall survival (OS) was significantly longer (23.2 vs 11.6 months; P <.0001) in the former compared with the latter subgroup.

Multivariable analyses involving the MCR cohort revealed male sex (hazard ratio [HR], 1.79; compared with female sex; P =.002), and higher tumor stage (HR, 2.31 for T3 compared with T1: P <.001) to be adverse prognostic factors. Conversely, use of adjuvant chemotherapy (HR, 0.45 vs no adjuvant chemotherapy; P <.001), intraoperative heated chemotherapy (IOHC; HR, 0.60 vs no IOHC; P =.024), and epithelioid histology (HR, 0.62 vs biphasic histology; P =.003) were shown to be associated with improved OS.

In their concluding remarks, the study investigators commented that “this study confirms that [pleurectomy decortication] can be performed with a low 30- and 90-day mortality and establishes the complication and outcome profile in a very large patient cohort from a single institution.”

They further added that “these results support continuing surgical therapy as part of multi-modality treatment for patients with MPM and should provide a basis for future studies.”

References

  1. Lapidot M, Gill RR, Mazzola E, et al. Pleurectomy decortication in the treatment of malignant pleural mesothelioma: Encouraging results and novel prognostic implications based on experience in 355 consecutive patients. Ann Surg. Published online December 3, 2020.  doi: 10.1097/SLA.0000000000004306
  2. National Comprehensive Cancer Network (NCCN) Malignant Pleural Mesothelioma Guidelines V1.2021. Accessed December 14, 2020.