Extended Pleurectomy/Decortication for Malignant Pleural Mesothelioma: Humanitas’s Experience

Abstract

Background: We analysed a series of malignant pleural mesothelioma (MPM) patients who consecutively underwent extended Pleurectomy/Decortication (eP/D) in a centre with a high level of thoracic surgery experience (IRCCS Humanitas Research Hospital) to explore postoperative morbidity and mortality, pattern of recurrence and survival. Methods: A retrospective analysis was performed on MPM patients underwent eP/D in our centre from 2010 to 2021. All patients were identified from our departmental database. Postoperative complications were scored according to Clavien–Dindo criteria. Survival analysis was performed by the Kaplan–Meier methods and Cox multivariable analysis. Results: Eighty-five patients underwent extended pleurectomy decortication (eP/D) during study period. Macroscopical residual disease (R2) was reported in one case. A neoadjuvant chemotherapy regiment was administrated in 88% of the surgical cohort. A complete trimodality treatment including induction with platinum agents and pemetrexed, radical cytoreductive surgery and volumetric modulated arc therapy technology (VMAT) could be administered in 63 patients (74%). Postoperative morbidity rate was 54.11%, major complications (defined as Clavien–Dindo ≥ 3) were reported in 11 patients (12.9%). Thirty-day mortality and 90-day mortality were, respectively, 2.35% and 3.53%. Median disease-free and overall survival were, respectively, 13.7 and 25.5 months. The occurrence of major complications (Clavien–Dindo ≥ 3), operative time, pT3–T4, pathological node involvement (pN+) were prognostic factors associated with worse survival. Conclusions: In our experience, eP/D is a well-tolerated procedure with acceptable mortality and morbidity, allowing for the administration of trimodality regimens in most patients. eP/D offered in a multimodality treatment setting have satisfactory long term oncological results. To obtain best oncological results the goal of surgery should be macroscopic complete resection in carefully selected patients (clinical N0).

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

“…This evidence was confirmed by our recent study in which we compared our initial surgical experience with ePD vs. EPP in treating MPM: only the 31% of our patients submitted for EPP were capable to tolerate a trimodality treatment [ 9 ]. The current study confirmed these data, considering that only 32% of patients in the EPP group were able to benefit from a full trimodality course compared to 74% of the patients in the eP/D group [ 10 ]. A possible explication of these data is the fact that the clinical impact of eP/D on patient general condition was apparently less severe, allowing most patients to complete trimodality regimens [ 24 ].…”

“…In two recent studies we have already described our treatment strategy [ 9 , 10 ]. The general performance status and the cardiopulmonary reserve were systematically evaluated during pretreatment assessment.…”

Association between thoracic epidural block and major complications after pleurectomy/decortication for malignant pleural mesothelioma under general anesthesia

“…We performed multivariable logistic regression analyses to determine the association between epidural block and major complications. Since no multicollinearity existed between candidate variables, eight variables of age≥70 years, male sex, BMI≥25 kg·m −2 , ASA-PS≥III, preoperative CRP levels≥1.00 mg·dL −1 ,18 epidural block, mean NR≥0.83,19 and RBC transfusion volume≥1200 mL7 were selected as candidate variables. Multivariable logistic regression revealed that the absence of epidural analgesia was an independent risk factor for major complications (table 2).…”

“…Since the perioperative morbidity and mortality folllowing P/D are lower than those with EPP, P/D has recently been preferred over EPP as the first-choice surgical procedure 3–5. The incidence of major complications within 30 days after surgery, however, is still high even after P/D (13%–51%),4–7 corresponding to that after EPP (27%–45%) 5 6 8. Our previous study, however, reported that no risk factor for postoperative complications was observed in perioperative variables in P/D 5…”

Anaesthetic and perioperative considerations for extrapleural pneumonectomy and extended pleurectomy/decortication: a scoping review protocol

“…In contrast to EPP, ePD has seen increasing popularity as the surgical-technique-of-choice for PM debulking—with some studies reporting lower 30-day mortality rates of 2.35% and improved overall survival time. 38 39 Given intraoperative and postoperative complications are not uncommon for either EPP or ePD, there are major impacts on quality of life and long-term survival, in addition to implications for health resource management.…”