Systematic Review and Meta-Analysis of Pleurectomy/Decortication versus Extrapleural Pneumonectomy in the Treatment of Malignant Pleural Mesothelioma

Abstract

Objective: Malignant pleural mesothelioma (MPM) is a rare and aggressive malignant cancer for which there are poor treatment options. Extrapleural pneumonectomy (EPP) and pleurectomy decortication (P/D) are the two most used surgical procedures in patients with resectable disease. We reviewed the available literature in order to compare the overall survival and postoperative complications of EPP and P/D and to provide evidence for the best procedure in the treatment of MPM. Methods: We performed a systematic review of the literature, including studies from August 2018 to May 2022. The primary outcome was 5-year overall survival (OS) and the secondary outcomes were 30-day mortality, 90-day mortality and peri-operative complications. Results: Thirteen studies were considered, including a total of 1624 patients treated with EPP and 2147 treated with P/D. The estimated pooled HR showed a significant lower hazard for P/D compared to EPP in terms of OS (HR = 0.76; 95% CI from 0.62 to 0.94; p < 0.001). In 12 studies, the risk for 30-day mortality was lower for patients treated with P/D (RR = 0.49; 95% CI from 0.31 to 0.76; p = <0.01), whereas only five studies reported 90-day mortality, and no statistically significant difference between EPP and P/D was found (RR = 0.71; 95% CI from 0.47 to 1.07; p = 0.10). The OS restricted mean survival time difference meta-analysis (RMSDT) confirms the superior survival of P/D on the EPP, a superiority that increases from 0.54 months at one year to 4.23 at five years. The incidence of postoperative empyema, atrial fibrillation, bleeding and bronchopleural fistula was significantly increased in the EPP group except for prolonged air leakage, which is only characteristic of P/D. Conclusions: Using two different statistical methods, this meta-analysis suggests that long-term survival after surgical treatment for resectable MPM is greater for patients undergoing P/D. Long-term survival had never been previously analyzed with appropriate tests; on the contrary, our result is consistent with the previous meta-analyses and reinforces the evidence of lower 30-day mortality and the prevalence of postoperative complications in P/D versus EPP patients. The recent introduction of innovative therapeutic schemes, both adjuvant and neoadjuvant therapy, keeps the discussion on surgical strategy open and will require new studies.

Individualized prediction of survival benefit from postoperative radiotherapy for patients with malignant pleural mesothelioma

“…We believe that the logic for MCR is obvious. In addition, the surgical approach to a less radical lung‐sparing technique (PD) may improve OS compared with invasive EPP 25–27 . Our study also demonstrated that histologic subtype had great impact on survival, and epithelioid subtype formed a sizable majority and was associated with better survival compared with biphasic and sarcomatoid subtypes, which is consistent with previous studies 28–31 .…”

“…In addition, the surgical approach to a less radical lung-sparing technique (PD) may improve OS compared with invasive EPP. [25][26][27] Our study also demonstrated that histologic subtype had great impact on survival, and epithelioid subtype formed a sizable majority and was associated with better survival compared with biphasic and sarcomatoid subtypes, which is consistent with previous studies. [28][29][30][31] Meyerhoff et al confirmed that surgical intervention was correlated with improved prognosis in epithelioid subtype but not in biphasic and sarcomatoid subtypes.…”

A deep learning-based model (DeepMPM) to help predict survival in patients with malignant pleural mesothelioma

“…Surgery is the first-choice treatment in early-stage MPM and mainly includes pleurectomy/decortication (P/D) or extrapleural pneumonectomy (EPP) ( 14 , 15 ). A meta-analysis showed that patients undergoing P/D had a significantly lower 5-year OS than did those undergoing EPP (HR =0.76; 95% CI: 0.62–0.94; P<0.001), as well as a lower 30-day mortality and postoperative complications rate ( 16 ). For unresectable MPM, antifolate drugs pemetrexed plus cisplatin have been shown to improve the survival of patients ( 17 ).…”

Malignant Pleural Mesothelioma

“…Although there is controversy as to which procedure is better, lung sparing macroscopic resection was associated with comparable long-term outcomes with lower perioperative mortality [63]. P/D is associated with better long term survival for resectable MPM however post operative complications were higher in this group [64].…”