A systematic review of lung-sparing extirpative surgery for pleural mesothelioma

Abstract

SummaryObjectives There is a resurgence of interest in lung-sparing extirpative surgery for malignant pleural mesothelioma with recent reports of better survival and fewer adverse consequences than with extrapleural pneumonectomy. However, these operations are not well-characterized and to offer evidence-based clinical recommendations and to plan future trials a summary of what is already known is required.Design A formal literature search was performed and all recovered titles were sequentially sifted by title, abstract and full-text reading according to prespecified criteria. Papers were selected if they contained data relevant to the area of enquiry. Quantitative synthesis and textual analysis, appropriate to the material, were performed.Setting Follow-up studies of patients undergoing surgery for malignant pleural mesothelioma in specialist thoracic or cardiothoracic units.Participants Among the operated patients described in these papers, a total of 1270 patients had undergone lung-sparing surgery for mesothelioma.Results There were no randomized trials or other forms of controlled studies. From 464 titles, 26 papers contained sufficient data on 1270 patients to be included in the systematic review. Operative descriptions for all series were extracted and tabulated and variation was found in the nature of surgery within and between series, and the degree of detail with which it was described. There was more operative detail in recent papers. All available numerical data were extracted, tabulated and summarized using quantitative methods. The average survival at 1, 2, 3, 4 and 5 years was 51%, 26%, 16%, 11% and 9%, respectively. There were no data on patients' performance status, symptomatic change, or other patient reported outcomes.

Efficacy and cost of video-assisted thoracoscopic partial pleurectomy versus talc pleurodesis in patients with malignant pleural mesothelioma (MesoVATS): an open-label, randomised, controlled trial

“…29 The reason for the improvement in cost-effectiveness is multifactorial. After study midpoint, trial patients undergoing VAT-PP had a slightly lower median hospital stay than did earlier patients (7 days [IQR 5-7] vs 8 days [6][7][8][9][10][11]) whereas patients with talc pleurodesis had a very similar but slightly higher median hospital stay than did earlier patients (4 days [2][3][4][5][6][7] vs 3 days [2][3][4][5]), resulting from greater use of thoracoscopy and talc poudrage in the second half of the trial (appendix), which is more expensive (talc pleurodesis cost £1129 in the first half of the trial and £2649 in the second half). Additionally, we noted some evidence of a greater difference between the groups in EQ-5D score at 6 and 12 months in the second half of the trial, whereas survival remained similar for the two groups (appendix).…”

“…6 Extrapleural pneumonectomy (EPP) has been assessed in several studies-most recently in the MARS trial 7 as part of trimodality therapy. Lung-sparing approaches, including (extended) pleurectomy with decortication [8][9][10] and video-assisted thoracoscopic partial pleurectomy (VAT-PP), have also been assessed, 11,12 and might be particularly appropriate for patients with more advanced disease or comorbidities.…”

Malignant pleural mesothelioma and the Society of Thoracic Surgeons Database: An analysis of surgical morbidity and mortality

“…11 In a separate systematic review of 1270 patients undergoing PD for MPM within 26 series, operative mortality ranged from 0% to 25%, with a weighted average of 4%. 12 Similar to other complex procedures, such as pneumonectomy and esophagectomy, the morbidity and mortality of EPP (and PD) might be expected to be lower at higher-volume centers, [13][14][15] although this remains unproven.…”

Surgery for malignant pleural mesothelioma: an international guidelines review

“…On the one hand EPP seems to be more radical than P/D (13,14), on the other hand P/D appears to have lower mortality and morbidity rate (15,16). Because of the absence of randomized trials comparing long term survival and results of P/D and EPP, which is the best surgical procedure remains clouded.…”