Surgical Management of Malignant Pleural Mesothelioma: Impact of Surgery on Survival and Quality of Life—Relation to Chemotherapy, Radiotherapy, and Alternative Therapies

Abstract

Introduction. Malignant pleural mesothelioma (MPM) is an aggressive cancer arising from pleural mesothelium. Surgery aims to either cure the disease or control the symptoms. Two surgical procedures exist: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). In this systematic review we assess current evidence on safety and efficacy of surgery. Methods. Five electronic databases were reviewed from January 1990 to January 2013. Studies were selected according to a predefined protocol. Primary endpoint was overall survival. Secondary endpoints included quality of life, disease-free survival, disease recurrence, morbidity, and length of hospital stay. Results. Sixteen studies were included. Median survival ranged from 8.1 to 32 months for P/D and from 6.9 to 46.9 months for EPP. Perioperative mortality was 0%–9.8% and 3.2%–12.5%, respectively. Perioperative morbidity was 5.9%–55% for P/D and 10%–82.6% for EPP. Average length of stay was 7 days for P/D and 9 days for EPP. Conclusion. Current evidence cannot definitively answer which procedure (EPP or P/D) is more beneficial in terms of survival and operative risks. This systematic review suggests that surgery in the context of trimodality therapy offers acceptable perioperative outcomes and long-term survival. Centres specialising in MPM management have better results.

Short‐term outcomes of pleurectomy decortication and extrapleural pneumonectomy in mesothelioma

“…We identified all original research studies evaluating 30‐day mortality and postoperative complications of EPP versus P/D in the National Library of Medicine and National Institutes of Health PubMed database from January 1990 to December 2017 using the following keyword search terms: “mesothelioma,” “pleurectomy,” “pneumonectomy,” “pneumectomy,” “30‐day mortality,” “survival,” “complications,” and “morbidity.” Three previous reviews were evaluated for citation of eligible articles . Articles were considered eligible if: (1) written in English, (2) observational study, (3) compared EPP to P/D, (4) included sample size > 20 patients, and (5) compared 30‐day mortality or postoperative complication rate by surgical approach.…”

“…Three previous reviews were evaluated for citation of eligible articles. 4,5,9 Articles were considered eligible if: (1) written in English, (2) Surgery type was defined using the following ICD-9-CM procedure codes: 345 and 3451 for P/D and 325 and 3259 for EPP. Patients without a patient identifier (n = 6), or who never received any MPM treatment between 1995 and 2012 (n = 2123) or only received thoracoscopic surgery (n = 39) were excluded.…”

Meta-Analysis of Survival After Pleurectomy Decortication Versus Extrapleural Pneumonectomy in Mesothelioma

“…The search strategy included the following keyword search terms: "mesothelioma", "pleurectomy", "pneumonectomy", "pneumectomy", and "malignant pleural mesothelioma", and spanned from January 1990 to January 2014. In addition, references included in 2 previously published reviews [2,3] were reviewed. Reference lists from all retrieved articles were also reviewed in search of additional eligible articles.…”

“…Two systematic reviews have been previously published, but both were subject to significant limitations. One review [3] included studies that analyzed either one or the other procedure (without comparing the 2) rather than excluding studies that did not compare the 2 surgical techniques. A recent meta-analysis [2] that included studies comparing the 2 procedures was incomplete (only 7 trials were analyzed).…”

Current and prospective pharmacotherapies for the treatment of pleural mesothelioma

“…However, more effective outcomes are obtained when surgery is combined with adjuvant therapy such as chemotherapy or radiotherapy, with survival increasing slightly from ten months to twenty months 8,11,12 . Despite this, a systematic review carried out by Papaspyros and Papaspyros indicates that results from surgery are conflicting, with some studies indicating poor survival or no difference between patients treated surgically and those not, whilst the overall thought is that surgery as part of trimodality therapy offers long-term survival 13 . However, the authors also indicated that specialised centres demonstrated better results, which may present a complication in translating observed therapeutic benefits to the wider population 13 .…”