Role of partial pleurectomy and extended pleurectomy/decortication in mesothelioma: a narrative review

Introduction

Background

Malignant pleural mesothelioma (MPM) is an aggressive and rare tumour originating in the pleurae (1). The vast majority of MPM diagnoses have been related to well-known occupational asbestos exposure (2) while less common risk factors unrelated to asbestos are exposure to erionite, ionizing radiation and germline mutations (3,4). There are three main histological groups of MPM: epithelioid, sarcomatoid and biphasic (5); the epithelioid is the most common group and shows the better prognosis; on the contrary sarcomatoid and biphasic MPM—biphasic being a mixed form of both epithelioid and sarcomatoid forms—are less frequent and associated with the poorest prognosis (6,7).

MPM prognosis is globally very poor, showing a median overall survival (OS) ranging from 8 to 14 months (3); only limited therapeutic options are nowadays available, thus making MPM treatment an emerging field for preclinical experimental approaches (8-10).

Surgical procedures for MPM may range from relatively minor operations to obtain a clear histopathologic diagnosis, to more demanding debulking procedures for palliation or with cytoreductive aim (11).

When the goal of the procedure is to improve OS by cytoreducing pleural disease to a microscopic residual one, extrapleural pneumonectomy (EPP), extended pleurectomy/decortication (EPD) or pleurectomy/decortication (PD) have been advocated—through the years—as the ideal options within a multimodality therapeutic approach (12-15); on the contrary, when the target of the procedure is a palliative control of symptoms like pleural effusions and pain, partial pleurectomy—via open or thoracoscopic approach—and video-assisted talc poudrage (VTP) are presently considered as the best therapeutic options (16,17). While EPP has been clearly described and standardised by many groups (12-15), the definition of PD still remains quite variable with regard both to surgical technique and final goals (18), although EPD definition is currently being standardized by the EORTC 1205 trial, of which results are expected in Q1 2023 (19).

In the recently published ERS/ESTS/EACTS/ESTRO guidelines for the management of MPM, chemotherapy has been shown to have limited efficacy, and only selected patients are described as suitable candidates for radical surgery. New encouraging immunotherapies, as well as targeted therapies have been reviewed. Due to limited data on the ideal combination treatment, ERS/ESTS/EACTS/ESTRO guidelines disclosed that patients potentially candidates for a multimodal treatment, including radical surgery, should be enrolled in clinical trials in MPM-dedicated centres, whenever possible (20).

Intensity modulated pleural radiation therapy has been shown to be safe with an acceptable rate of radiation pneumonitis; together with chemotherapy and PD in has been advocated as a new lung-sparing treatment paradigm for patients with locally advanced MPM, yielding acceptable locoregional control (21,22).

We present the following article in accordance with the Narrative Review reporting checklist (available at https://shc.amegroups.com/article/view/10.21037/shc-21-34/rc).

Objectives

The aim of this unsystematic narrative review is to assess the role of partial pleurectomy in the treatment of MPM.

Methods

This is an unsystematic narrative review of previously published information about partial PD for MPM.

Sources of information

Research has been done by accessing the following data bases: Medline; Cochrane database of systematic reviews.

Search terms delimiting

Malignant pleural mesothelioma; pleurectomy decortication; palliative pleurectomy; extrapleural pneumonectomy, indwelling pleural catheters; VATS talc pleurodesis.

Selection criteria employed

Inclusion criteria: papers written in English about surgical treatment of MPM from the above mentioned data bases [1976–2020] (Table 1).

Discussion

PD has been one of therapeutic option for MPM during the last forty years as reported by Martini et coll. which disclosed in 1976 a median OS of 21 months after this operation combined with chemo-radiotherapy (23).

The aim of this procedure is to resect all the visible tumour for the lung, fissures, chest wall, diaphragm and mediastinal structures, usually via postero-lateral or lateral standard thoracotomy.

Not infrequently PD can be effectively accomplished after talc poudrage which does not represent a contraindication and could even make pleural dissection form lung parenchyma easier. Some Authors reported the combination of PD with intraoperative chemotherapy or adjuvant treatments like post operative chemotherapy alone or combined to immunotherapy, although clear benefits in terms of OS are still controversial (16,24).

Although some concerns still exist about the role of adjuvant high-dose radiotherapy following PD because of the presence of the lung that is still in-situ and could suffer from severe radiation pneumonitis (25), the introduction of pleural intensity-modulated radiation therapy (IMRT) allowed a safer although technically challenging delivering radiation (26).

It has been reported an acceptable operative mortality rate of 4% with 2-year survival rate of 26% and 5-year survival rate of 9% (27). In the light of its relatively low morbidity and mortality rate, PD and EPD have been recently advocated as a potential alternative to EPP: several groups, in fact, disclosed same survivals after EPP and PD with a definitely lower mortality rate and higher post operative quality of life of PD (28-33). In particular, pulmonary function shows a faster and better improvement in patients submitted PD rather than EPP with a better postoperative global performance status allowing the completion of multimodality treatment with adjuvant therapies (34).

Video assisted thoracoscopic surgery (VATS) is the gold standard approach for obtaining a reliable histologic diagnosis in patients which might further benefit from additional surgery with radical intent; on the other hand, medical thoracoscopy is a valuable option for patients not amenable of radical surgery because of poor performance status or significant comorbidities, although the main reason for not being amenable for surgery is advanced disease (35,36). Patients presenting trapped lung—with no chance of re-ventilation—can not benefit form talc pleurodesis but could be considered for pleurectomy or long-term chest drainage placement (indwelling pleural catheters or pleurocaths). VATS pleurectomy in patients with MPM and trapped lung could provide complete or partial pulmonary re-expansion, ameliorating respiratory performances and overall quality of life (37-40).

In 2014 the MesoVATS trial’s results have been published; it was an open-label, parallel-group, randomised, controlled trial randomizing patients aged 18 years or older with any subtype of confirmed or suspected mesothelioma with pleural effusion, to either VATS pleurectomy or talc pleurodesis and no survival benefit has been showed in the VATS pleurectomy group. Fort this reason VATS pleurectomy was not recommended to ameliorate OS of MPM patient and VATS talc poudrage was suggested because of its lower complication rate and shorter hospital stay as well. On the other hand, patients submitted to VATS pleurectomy—rather than talc poudrage—showed a significantly better quality of life both at 6 and 12 months after the procedure (41). Nevertheless, it should be always taken into consideration that PD—although definitely less invasive than EPP—is not without any complications, in particular when performed in older patients or with significant comorbidities (38); haemorragic complications as well as prolonged air leaks may frequently occurred after PD and so the expected advantages of the procedure should always be carefully evaluated according to the global performance status of the patient.

There are several limits on this multicentric study which required nearly 10 years to complete its accrual: during this period, daily clinical practices worldwide evolved from those reported in this study. Positron-emission tomography (PET) and/or magnetic resonance imaging (MRI) were more frequently used for preoperative staging and VTP was chosen over talc slurry via chest drainage. These modifications—together with some patients’ exclusion from the trial—significantly affected some conclusions of the study. In fact, many results of this study are based only on subsets of enrolled patients, and so they should be carefully considered when applied to clinical practice (42).

Indwelling pleural catheters represent another palliative option for treating pleural effusion in MPM patients: they do not require hospitalization as they can be easily implanted in the outpatient setting and caregivers or patients themselves can safely manage at home to treat recurrent pleural effusion not amenable of effective talc pleurodesis (43,44). Some studies show even better results of indwelling pleural catheters when compared with talc pleurodesis (43,44), in our personal experience, two different types of indwelling pleural catheters were able to effectively palliate symptoms in case of trapped lung (45).

With regard to long-term results, in our personal experience, we observed similar long-term outcomes results of EPD and standard PD; on the other hand, they both disclosed a clear survival advantage over partial pleurectomy (46). Moreover, no difference in terms of postoperative mortality rate was observed between the three types of PD (extended, standard and partial), while a significantly higher postoperative morbidity rate was observed in extended and standard pleurectomy when compared to partial pleurectomy (46).

The unsatisfactory results provided by partial pleurectomy—with regard to long term survival—raise the question of the appropriateness of this procedure; in addition, the palliative role of partial pleurectomy—that could be emphasized by its low postoperative morbidity rate—is still debated and some doubts remain about its real impact on quality of life improvement, pain control, pleural effusion recurrence prevention as well as chest wall and soft tissue invasion (46,47).

In a recent systematic review about the role of pleurectomy in the treatment of MPM by Cao et al., partial pleurectomy showed a perioperative mortality rate ranging from 0% to 7.8% and overall perioperative morbidity rate ranging from 14% to 20% with a mean total length of in-hospital stay ranging from 6 to 11 days (48). As reported in previous studies, both disease-free and median OS outcomes were shown to be longer in patients receiving extended PD compared to standard PD and partial pleurectomy; this might be probably due to the increased chance to obtain complete macroscopic disease resection by removing the pericardium and the diaphragm whenever these surfaces are involved by the tumour. Interestingly, these better results are balanced by higher morbidity and a longer in- hospital stay (48).

The histological subtype is relevant when surgery is considered for MPM, and most guidelines recommend excluding sarcomatoid mesothelioma; this histologic type, in fact, as the biphasic type, does not benefit from surgery because of its biological behaviour and only symptoms control should be the target of surgeons in this setting.

Summary

In conclusion, partial pleurectomy and decortication for MPM plays a role in the palliative approach to the disease, in particular to control recurrent pleural effusion; its impact on disease free and OS is very limited. Considering valuable alternatives to partial pleurectomy for controlling pleural effusion, such as VATS talc pleurodesis or indwelling pleural catheters, its indication should be carefully considered in fit patients with a longer life-expectancy, although its low morbidity and mortality rate is a favourable aspect to take into consideration during the final decisional process.

Acknowledgments

The English text has been edited by Susan Jane West.

Funding: This work was partially supported by the Italian Ministry of Health with “Ricerca Corrente”, “5×1000” funds.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Rahul Nayak) for the series “Management of Pleural Diseases in the 21st Century” published in Shanghai Chest. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://shc.amegroups.com/article/view/10.21037/shc-21-34/rc

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://shc.amegroups.com/article/view/10.21037/shc-21-34/coif). The series “Management of Pleural Diseases in the 21st Century” was commissioned by the editorial office without any funding or sponsorship. FP and LS served as unpaid editorial board members of Shanghai Chest. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Baas P, Daumont MJ, Lacoin L, et al. Treatment patterns and outcomes for patients with malignant pleural mesothelioma in England in 2013-2017: A nationwide CAS registry analysis from the I-O Optimise initiative. Lung Cancer 2021;162:185-93. [Crossref] [PubMed]
2. Howel D, Arblaster L, Swinburne L, et al. Routes of asbestos exposure and the development of mesothelioma in an English region. Occup Environ Med 1997;54:403-9. [Crossref] [PubMed]
3. Bibby AC, Tsim S, Kanellakis N, et al. Malignant pleural mesothelioma: an update on investigation, diagnosis and treatment. Eur Respir Rev 2016;25:472-86. [Crossref] [PubMed]
4. van Kaick G, Dalheimer A, Hornik S, et al. The german thorotrast study: recent results and assessment of risks. Radiat Res 1999;152:S64-71. [Crossref] [PubMed]
5. Alì G, Bruno R, Fontanini G. The pathological and molecular diagnosis of malignant pleural mesothelioma: a literature review. J Thorac Dis 2018;10:S276-84. [Crossref] [PubMed]
6. Rusch VW, Giroux D. Do we need a revised staging system for malignant pleural mesothelioma? Analysis of the IASLC database. Ann Cardiothorac Surg 2012;1:438-48. [PubMed]
7. Taioli E, Wolf AS, Camacho-Rivera M, et al. Determinants of Survival in Malignant Pleural Mesothelioma: A Surveillance, Epidemiology, and End Results (SEER) Study of 14,228 Patients. PLoS One 2015;10:e0145039. [Crossref] [PubMed]
8. Facchetti G, Petrella F, Spaggiari L, et al. Malignant Pleural Mesothelioma: State of the art and advanced cell therapy. Eur J Med Chem 2017;142:266-70. [Crossref] [PubMed]
9. Petrella F, Rimoldi I, Facchetti G, et al. Novel platinum agents and mesenchymal stromal cells for thoracic malignancies: state of the art and future perspectives. Expert Opin Ther Pat 2018;28:813-21. [Crossref] [PubMed]
10. Petrella F, Coccè V, Masia C, et al. Paclitaxel-releasing mesenchymal stromal cells inhibit in vitro proliferation of human mesothelioma cells. Biomed Pharmacother 2017;87:755-8. [Crossref] [PubMed]
11. Rice D, Rusch V, Pass H, et al. Recommendations for uniform definitions of surgical techniques for malignant pleural mesothelioma: a consensus report of the international association for the study of lung cancer international staging committee and the international mesothelioma interest group. J Thorac Oncol 2011;6:1304-12. [Crossref] [PubMed]
12. Wolf AS, Daniel J, Sugarbaker DJ. Surgical techniques for multimodality treatment of malignant pleural mesothelioma: extrapleural pneumonectomy and pleurectomy/decortication. Semin Thorac Cardiovasc Surg 2009;21:132-48. [Crossref] [PubMed]
13. Sugarbaker DJ, Richards WG, Garcia JP. Extrapleural pneumonectomy for malignant mesothelioma. Adv Surg 1997;31:253-71. [PubMed]
14. Sugarbaker DJ, Wolf AS. Surgery for malignant pleural mesothelioma. Expert Rev Respir Med 2010;4:363-72. [Crossref] [PubMed]
15. Casiraghi M, Maisonneuve P, Brambilla D, et al. Induction chemotherapy, extrapleural pneumonectomy and adjuvant radiotherapy for malignant pleural mesothelioma. Eur J Cardiothorac Surg 2017;52:975-81. [Crossref] [PubMed]
16. Richards WG, Zellos L, Bueno R, et al. Phase I to II study of pleurectomy/decortication and intraoperative intracavitary hyperthermic cisplatin lavage for mesothelioma. J Clin Oncol 2006;24:1561-7. [Crossref] [PubMed]
17. Pass H. Surgery and mesothelioma: if not randomization, at least standardization and registration! Lung Cancer 2011;71:1-2. [Crossref] [PubMed]
18. Rusch VW. Pleurectomy/decortication and adjuvant therapy for malignant mesothelioma. Chest 1993;103:382S-4S. [Crossref] [PubMed]
19. Raskin J, Surmont V, Cornelissen R, et al. A randomized phase II study of pleurectomy/decortication preceded or followed by (neo-)adjuvant chemotherapy in patients with early stage malignant pleural mesothelioma (EORTC 1205). Transl Lung Cancer Res 2018;7:593-8. [Crossref] [PubMed]
20. Opitz I, Scherpereel A, Berghmans T, et al. ERS/ESTS/EACTS/ESTRO guidelines for the management of malignant pleural mesothelioma. Eur J Cardiothorac Surg 2020;58:1-24. [Crossref] [PubMed]
21. Arrieta O, Lozano-Ruiz F, Blake-Cerda M, et al. Locoregional control and toxicity after pleurectomy/decortication and intensity-modulated pleural radiation therapy in patients with malignant pleural mesothelioma. Thorac Cancer 2020;11:3448-55. [Crossref] [PubMed]
22. Rimner A, Zauderer MG, Gomez DR, et al. Phase II Study of Hemithoracic Intensity-Modulated Pleural Radiation Therapy (IMPRINT) As Part of Lung-Sparing Multimodality Therapy in Patients With Malignant Pleural Mesothelioma. J Clin Oncol 2016;34:2761-8. [Crossref] [PubMed]
23. Wanebo HJ, Martini N, Melamed MR, et al. Pleural mesothelioma. Cancer 1976;38:2481-8. [Crossref] [PubMed]
24. Rusch V, Saltz L, Venkatraman E, et al. A phase II trial of pleurectomy/decortication followed by intrapleural and systemic chemotherapy for malignant pleural mesothelioma. J Clin Oncol 1994;12:1156-63. [Crossref] [PubMed]
25. Lee TT, Everett DL, Shu HK, et al. Radical pleurectomy/decortication and intraoperative radiotherapy followed by conformal radiation with or without chemotherapy for malignant pleural mesothelioma. J Thorac Cardiovasc Surg 2002;124:1183-9. [Crossref] [PubMed]
26. Rosenzweig KE. Radiation Therapy for Malignant Pleural Mesothelioma. Thorac Surg Clin 2020;30:473-80. [Crossref] [PubMed]
27. Teh E, Fiorentino F, Tan C, et al. A systematic review of lung-sparing extirpative surgery for pleural mesothelioma. J R Soc Med 2011;104:69-80. [Crossref] [PubMed]
28. Martin-Ucar AE, Nakas A, Edwards JG, et al. Case-control study between extrapleural pneumonectomy and radical pleurectomy/decortication for pathological N2 malignant pleural mesothelioma. Eur J Cardiothorac Surg 2007;31:765-70; discussion 770-1. [Crossref] [PubMed]
29. Flores RM, Pass HI, Seshan VE, et al. Extrapleural pneumonectomy versus pleurectomy /decortication in the surgical management of malignant pleural mesothelioma: results in 663 patients. J Thorac Cardiovasc Surg 2008;135:620-6. [Crossref] [PubMed]
30. Lang-Lazdunski L, Bille A, Belcher E, et al. Pleurectomy/decortication, hyperthermic pleural lavage with povidone-iodine followed by adjuvant chemotherapy in patients with malignant pleural mesothelioma. J Thorac Oncol 2011;6:1746-52. [Crossref] [PubMed]
31. Friedberg JS, Culligan MJ, Mick R, et al. Radical pleurectomy and intraoperative photodynamic therapy for malignant pleural mesothelioma. Ann Thorac Surg 2012;93:1658-65; discussion 1665-7. [Crossref] [PubMed]
32. Bölükbas S, Manegold C, Eberlein M, et al. Survival after trimodality therapy for malignant pleural mesothelioma: Radical Pleurectomy, chemotherapy with Cisplatin/Pemetrexed and radiotherapy. Lung Cancer 2011;71:75-81. [Crossref] [PubMed]
33. Lang-Lazdunski L, Bille A, Lal R, et al. Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma. J Thorac Oncol 2012;7:737-43. [Crossref] [PubMed]
34. Bölükbas S, Eberlein M, Schirren J. Prospective study on functional results after lung-sparing radical pleurectomy in the management of malignant pleural mesothelioma. J Thorac Oncol 2012;7:900-5. [Crossref] [PubMed]
35. Danby CA, Adebonojo SA, Moritz DM. Video-assisted talc pleurodesis formalignant pleural effusions utilizing local anesthesia and IV sedation. Chest 1998;113:739-42. [Crossref] [PubMed]
36. Stefani A, Natali P, Casali C, et al. Talc poudrage versus talc slurry in the treatment of malignant pleural effusion. A prospective comparative study. Eur J Cardiothorac Surg 2006;30:827-32. [Crossref] [PubMed]
37. Waller DA, Morritt GN, Forty J. Video-assisted thoracoscopic pleurectomy in the management of malignant pleural effusion. Chest 1995;107:1454-6. [Crossref] [PubMed]
38. Halstead JC, Lim E, Venkateswaran RM, et al. Improved survival with VATS pleurectomy-decortication in advanced malignant mesothelioma. Eur J Surg Oncol 2005;31:314-20. [Crossref] [PubMed]
39. Martin-Ucar AE, Edwards JG, Rengajaran A, et al. Palliative surgical debulking in malignant mesothelioma. Predictors of survival and symptom control. Eur J Cardiothorac Surg 2001;20:1117-21. [Crossref] [PubMed]
40. Nakas A, Martin-Ucar AE, Edwards JG, et al. The role of video-assisted thoracoscopic pleurectomy/decortication in the therapeutic management of malignant pleural mesothelioma. Eur J Cardiothorac Surg 2008;33:83-8. [Crossref] [PubMed]
41. Rintoul RC, Ritchie AJ, Edwards JG, et al. 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. Lancet 2014;384:1118-27. [Crossref] [PubMed]
42. Hoang CD. Surgical controversies in mesothelioma: MesoVATS addresses the role of surgical debulking. Transl Lung Cancer Res 2016;5:82-4. [PubMed]
43. Freeman RK, Ascioti AJ, Mahidhara RS. A propensity-matched comparison of pleurodesis or tunneled pleural catheter in patients undergoing diagnostic thoracoscopy for malignancy. Ann Thorac Surg 2013;96:259-63. [Crossref] [PubMed]
44. Hunt BM, Farivar AS, Vallières E, et al. Thoracoscopic talc versus tunneled pleural catheters for palliation of malignant pleural effusions. Ann Thorac Surg 2012;94:1053-7; discussion 1057-9. [Crossref] [PubMed]
45. Petrella F, Maisonneuve P, Borri A, et al. Pleural catheters after thoracoscopic treatment of malignant pleural effusion: a randomized comparative study on quality of life. J Thorac Dis 2018;10:2999-3004. [Crossref] [PubMed]
46. Marulli G, Breda C, Fontana P, et al. Pleurectomy-decortication in malignant pleural mesothelioma: are different surgical techniques associated with different outcomes? Results from a multicentre study. Eur J Cardiothorac Surg 2017;52:63-9. [Crossref] [PubMed]
47. Genovese E, Canì A, Rizzo S, et al. Comparison between MRI with spin-echo echo-planar diffusion-weighted sequence (DWI) and histology in the diagnosis of soft-tissue tumours. Radiol Med 2011;116:644-56. [Crossref] [PubMed]
48. Cao C, Thian HD, Patakya KA, et al. Systematic review of pleurectomy in the treatment of malignant pleural mesothelioma. Lung Cancer 2014;83:240-5. [Crossref] [PubMed]