Extrapleural pneumonectomy: still indicated?

Domen, Andreas; Berzenji, Lawek; Hendriks, Jeroen; Yogeswaran, Suresh Krishan; Lauwers, Patrick; Meerbeeck, Jan P. van; Schil, Paul Van

doi:10.21037/tlcr.2018.07.07

Cited by 9 publications

(5 citation statements)

References 33 publications

(78 reference statements)

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“…We therefore recommend that all patients scheduled for MCR undergo a preoperative assessment by spirometry and V/Q-scan to predict postoperative FEV1 and determine whether the healthy lung offers sufficient quality and functional reserve to tolerate an EPP (27). Our present data confirm that despite recent trends towards EPD, EPP performed in an experienced center may still offer a reasonable approach in selected cases with large tumor burden and extensive involvement of the lung parenchyma, but good functional reserve of the nonaffected lung (6,10,42,43). As a single-center study it needs to be highlighted, that external validity may be limited and the findings may not be generalizable.…”

Section: Outcomesupporting

confidence: 64%

The role of extrapleural pneumonectomy for malignant pleural mesothelioma: reviewing 20-years of experience

Werner¹,

Lauk²,

Opitz³

2020

Shanghai Chest

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Background: For patients with malignant pleural mesothelioma (MPM), a multimodality treatment concept including neoadjuvant chemotherapy and radical surgery offers improved overall survival. While the lung-sparing extended pleurectomy and decortication (EPD) has become the preferential surgical approach, the more aggressive extrapleural pneumonectomy (EPP) remains reserved for a selected group of patients.Based on our experience from the past two decades, we aim to discuss and assess today's role of EPP.Methods: Out of 523 MPM patients intended to be treated by induction chemotherapy followed by macroscopic complete resection between January 1999 and December 2019, we identified 151 consecutive patients who underwent EPP at our center. All patients were treated within a multimodality concept including neoadjuvant chemotherapy with platinum-based agents plus gemcitabine or pemetrexed. Clinical data were collected in an online database and analyzed retrospectively.Results: Of all patients, 57.6% were of IMIG stage IA or IB (n=87), 39.0% of all patients IMIG stage IIIA or IIIB (n=59). Mean tumor volume after induction chemotherapy was 294.6±315.0 cm 3 . Most patients were operated in the first decade between 1999 and 2009 [112 patients (74.2%)]. The overall 30-and 90-day mortality was 4.6% and 10.6%, respectively. The median overall survival was 18.5 months. Major postoperative morbidity was assessed as a composite outcome and occurred in 38.4% of all patients.Conclusions: Although EPD became the procedure of first choice, EPP is a reasonable approach in selected patients with high tumor burden and extensive involvement of the lung parenchyma, where parenchyma-sparing resection is technically not feasible or functionally not rational. All patients should be preoperatively assessed and informed about the eventuality of EPP, depending on intraoperative findings.

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Section: Outcomesupporting

confidence: 64%

The role of extrapleural pneumonectomy for malignant pleural mesothelioma: reviewing 20-years of experience

Werner¹,

Lauk²,

Opitz³

2020

Shanghai Chest

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“…In recent years, larger, multicenter, randomized trials have been started with the aim of reaching a consensus on effective treatment approaches. These studies induced a number of trends (for example, the shift from more radical approaches such as EPP to more conservative treatments such as lung-sparing surgery [P/D] 21 ). Even randomized controlled trials such as those by Treasure et al .…”

Section: Discussionmentioning

confidence: 99%

“…For a long time, EPP was the most widely used approach because it was considered the only way to obtain a macroscopic complete resection. It was hypothesized that EPP was less likely to leave residual tumor cells when compared with P/D; however, more recent studies have shown that in many cases neither EPP nor P/D results in complete R0 resections 21 . In recent years, there has been a shift in preference of surgeons toward an extended P/D instead of EPP.…”

Section: Surgical Resectionmentioning

confidence: 99%

Multimodality treatment of malignant pleural mesothelioma

Berzenji

Schil

2018

F1000Res

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Malignant pleural mesothelioma (MPM) is a rare disease of the pleura and is largely related to asbestos exposure. Despite recent advancements in technologies and a greater understanding of the disease, the prognosis of MPM remains poor; the median overall survival rate is about 6 to 9 months in untreated patients. The main therapeutic strategies for MPM are surgery, chemotherapy, and radiation therapy (RT). The two main surgical approaches for MPM are extrapleural pneumonectomy (EPP), in which the lung is removed en bloc, and pleurectomy/decortication, in which the lung stays in situ. Chemotherapy usually consists of a platinum-based chemotherapy, such as cisplatin, often combined with a folate antimetabolite, such as pemetrexed. More recently, immunotherapy has emerged as a possible therapeutic strategy for MPM. Evidence suggests that single-modality treatments are not an effective therapeutic approach for MPM. Therefore, researchers have started to explore different multimodality treatment approaches, in which often combinations of surgery, chemotherapy, immunotherapy, and RT are investigated. There is still no definitive answer to the question of which multimodality treatment combinations are most effective in improving the poor prognosis of MPM. Research into the effects of trimodality treatment approaches have found that radical approaches such as EPP and hemithoracic RT post-EPP are less effective than was previously assumed. In general, there are still a great number of unanswered questions and unknown factors regarding the ideal treatment approach for MPM. Hopefully, more research into multimodality therapy will provide insight into which combination of treatment modalities is most effective.

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“…However, the presence of unsurmountable anatomical limits and MPM’s diffuse nature make the goal of R0 surgery virtually unattainable. The execution of a very extensive resection procedure, such as extrapleural pneumonectomy (EPP), has been considered the best way to achieve a macroscopic complete resection for a long time [ 5 ]. Recently, several retrospective studies and meta-analyses have shown similar or lower long-term survivals and higher perioperative mortalities and postoperative morbidities in patients who have been treated with EPP compared to (e)P/D [ 6 , 7 ].…”

Section: Introductionmentioning

confidence: 99%

Single-Center 20-Year Experience in Surgical Treatment of Malignant Pleural Mesothelioma

Mangiameli

Bottoni

Cariboni

et al. 2022

JCM

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Objectives: We examined a series of malignant pleural mesothelioma (MPM) patients who consecutively underwent surgery in our institution during the last 20 years. Across this period, we changed our surgical approach to MPM, adopting extended pleurectomy and decortication (eP/D) instead of extrapleural pneumonectomy (EPP). In this study, we compare the perioperative outcomes and long-term survival of patients who underwent EPP vs. eP/D. Methods: A retrospective analysis was carried out of all the MPM patients identified from our departmental database who underwent EPP or P/D from 2000 to 2021. Clavien–Dindo criteria was adopted to score postoperative complications, while Kaplan–Meier methods and a Cox multivariable analysis were used to perform the survival analysis. Results: Of 163 patients, 78 (48%) underwent EPP and 85 (52%) eP/D. Induction chemotherapy was significantly administrated more often in the eP/D group (88% vs. 51%). Complete trimodality treatment including induction chemotherapy, radical surgery, and adjuvant radiotherapy was administered in 74% of the eP/D group versus 32% of the EPP group (p < 0.001). The postoperative morbidity rate was higher in the eP/D group (54%) compared to the EPP group (36%) (p = 0.02); no statistically significant differences were identified concerning major complications (EPP 43% vs. eP/D 24%, p = 0.08). No statistical differences were identified in 30-day mortality, 90-day mortality, median disease-free, and overall survival statistics between the two groups. The Cox multivariable analysis confirmed no induction chemotherapy (HR, 0.5; p = 0.002), RDW (HR, 1.08; p = 0.02), and the presence of pathological nodal disease (HR, 1.99; p = 0.001) as factors associated with worse survival in the entire series. Conclusions: Our data support that eP/D is a well-tolerated procedure allowing the implementation of a trimodality strategy (induction chemotherapy, surgery, and radiotherapy) in most MPM patients. When eP/D is offered in this setting, the oncological results are comparable to EPP. To obtain the best oncological results, the goal of surgical resection should be macroscopic complete resection (R0) in carefully selected patients (clinical N0).

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Extrapleural pneumonectomy: still indicated?

Cited by 9 publications

References 33 publications

The role of extrapleural pneumonectomy for malignant pleural mesothelioma: reviewing 20-years of experience

The role of extrapleural pneumonectomy for malignant pleural mesothelioma: reviewing 20-years of experience

Multimodality treatment of malignant pleural mesothelioma

Single-Center 20-Year Experience in Surgical Treatment of Malignant Pleural Mesothelioma

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