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Expert Review of Respiratory Medicine Jan 2020: Malignant pleural mesothelioma (MPM) is a fatal malignancy for which there is no definitive cure. The most effective multimodality treatment in prolonging survival is...
: Malignant pleural mesothelioma (MPM) is a fatal malignancy for which there is no definitive cure. The most effective multimodality treatment in prolonging survival is still matter of debate. Surgery remains one of the cornerstones in the multimodality therapy for MPM. Extra-pleural pneumonectomy and pleurectomy/decortication are the two main curative-intent procedures; however, the superiority of one technique over the other is still debated. This review aims to assess short- and long-term results of extrapleural pneumonectomy for MPM.: This article focuses on the role of extrapleural pneumonectomy in MPM. A systematic review was performed by using electronic databases to identify studies that included patients treated by this procedure for MPM. Endpoints included overall survival, disease-free survival, recurrence rate, perioperative mortality, and morbidity.: This paper offers an overview of the results that are currently obtained in patients undergoing extrapleural pneumonectomy for MPM. The benefit of surgical treatments in MPM is still debated and its primary goal should be the achievement of a macroscopic complete resection. Several alternative multimodality protocols exist, with specific advantages and drawbacks; therefore, individualization of care for each patient is fundamental. The complexity of the surgical treatment mandates that patients be referred to specialized centers.
Topics: Humans; Mesothelioma; Mesothelioma, Malignant; Pleural Neoplasms; Pneumonectomy; Treatment Outcome
PubMed: 31674841
DOI: 10.1080/17476348.2020.1688147 -
Journal of Clinical Medicine Sep 2022Objective: Malignant pleural mesothelioma (MPM) is a rare and aggressive malignant cancer for which there are poor treatment options. Extrapleural pneumonectomy (EPP)... (Review)
Review
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.
PubMed: 36233416
DOI: 10.3390/jcm11195544 -
Journal of Cardiothoracic Surgery Apr 2023Surgical approach is the most effective treatment for primary spontaneous pneumothorax. The two most widely adopted surgical methods are mechanical abrasion and apical... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Surgical approach is the most effective treatment for primary spontaneous pneumothorax. The two most widely adopted surgical methods are mechanical abrasion and apical pleurectomy, in addition to bullectomy. We performed a systematic review and meta-analysis to examine which technique is superior in treating primary spontaneous pneumothorax.
METHODS
PubMed, MEDLINE and EMBASE databases were searched for studies published between January 2000 to September 2022 comparing mechanical abrasion and apical pleurectomy for treatment of primary spontaneous pneumothorax. The primary outcome was pneumothorax recurrence. Secondary outcomes included post-operative chest tube duration, hospital length of stay, operative time and intra-operative of blood loss.
RESULTS
Eight studies were eligible for inclusion involving 1,613 patients. There was no difference in the rate of pneumothorax recurrence between pleural abrasion and pleurectomy (RR: 1.34; 95% CI: 0.94 to 1.92). However, pleural abrasion led to shorter hospital length of stay (MD: -0.25; 95% CI: -0.51 to 0.00), post-operative chest tube duration (MD: -0.30; 95% CI: -0.56 to -0.03), operative time (MD: -13.00; 95% CI -15.07 to 10.92) and less surgical blood loss (MD: -17.77; 95% CI: -24.36 to -11.18).
CONCLUSION
Pleural abrasion leads to less perioperative patient burden and shorter hospital length of stay without compromising the rate of pneumothorax recurrence when compared to pleurectomy. Thus, pleural abrasion is a reasonable first choice surgical procedure for management of primary spontaneous pneumothorax.
Topics: Humans; Pneumothorax; Pleura; Pleurodesis; Recurrence; Thoracic Surgical Procedures; Treatment Outcome; Thoracic Surgery, Video-Assisted
PubMed: 37024894
DOI: 10.1186/s13019-023-02207-3 -
The Journal of Surgical Research Apr 2017Numerous thoracoscopic techniques have been used in the management of primary spontaneous pneumothorax (PSP), including wedge resection, pleurectomy, pleural abrasion,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Numerous thoracoscopic techniques have been used in the management of primary spontaneous pneumothorax (PSP), including wedge resection, pleurectomy, pleural abrasion, chemical pleurodesis, and staple line covering. The purpose of this systematic review was to compare outcomes for the most commonly reported techniques.
MATERIALS AND METHODS
A systematic literature search looking at pneumothorax recurrence rate, length of stay, and chest tube duration after surgery was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed database.
RESULTS
Fifty-one unique studies comprised of 6907 patients published between January 1988 and June 2015 were identified. Heterogeneity among effect sizes was significant for all outcomes. The lowest recurrence rates were observed in the wedge resection + chemical pleurodesis (1.7%; 95% confidence interval [CI], 1.0%-2.7%) and the wedge resection + pleural abrasion + chemical pleurodesis (2.8%; 95% CI, 1.7%-4.7%) groups. The shortest chest tube duration and length of stay were observed in the wedge resection + staple line covering ± other group (2.1 d; 95% CI, 1.4-2.9 and 3.3 d; 95% CI, 2.6-4.0, respectively).
CONCLUSIONS
The variability in reported outcomes and the lack of published multicenter randomized controlled trials highlights a need for more robust investigations into the optimal surgical technique in the management of PSP. Based on the limited quality studies available, this systematic review favors wedge resection + chemical pleurodesis and wedge resection + pleural abrasion + chemical pleurodesis in terms of recurrence rate after surgery for PSP.
Topics: Humans; Pleurodesis; Pneumonectomy; Pneumothorax; Recurrence; Surgical Stapling; Thoracoscopy; Treatment Outcome
PubMed: 28457339
DOI: 10.1016/j.jss.2016.10.024 -
Practical Radiation Oncology 2020This review explores the use of intensity modulated radiation therapy (IMRT) after lung-sparing surgery in malignant pleural mesothelioma (MPM). Because severe... (Review)
Review
PURPOSE
This review explores the use of intensity modulated radiation therapy (IMRT) after lung-sparing surgery in malignant pleural mesothelioma (MPM). Because severe toxicities have been documented after radiation therapy for MPM, its use remains controversial, especially as modern surgical management has shifted toward lung-sparing pleurectomy/decortication. IMRT is an advanced technique that may allow for safer radiation therapy delivery, but there remains limited data (including no summative data) to support this notion.
METHODS AND MATERIALS
We performed a systematic review evaluating the safety and efficacy of post-pleurectomy IMRT (P-IMRT). A systematic review of PubMed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted for publications of all dates that specifically reported clinical outcomes and/or toxicities of P-IMRT in patients with MPM. Ten original studies were included in this review.
RESULTS
The incidence of grade 3 pneumonitis ranged from 0% to 16%, with all but 2 studies reporting rates below 9%. Grade 4 and 5 pneumonitis were observed in less than 1.5% of cases, except in one publication that used hypofractionated radiation therapy to doses >60 Gy. Crude local failure rates ranged from 19% to 60%, median progression free survival ranged from 12 to 16 months, and median overall survival ranged from 19 to 28 months.
CONCLUSIONS
P-IMRT produces relatively few higher-grade toxicities and has reasonable disease-related outcomes, especially when delivered using conventionally fractionated regimens to doses of 45 to 54 Gy and exercising careful attention to dose constraints during treatment planning. IMRT can thus be considered in well-selected patients in whom adequate survival after pleurectomy is expected. These data also support the initiation of the phase III NRG-LU006 trial of extended pleurectomy/decortication and chemotherapy with or without IMRT.
Topics: Humans; Lung; Mesothelioma; Mesothelioma, Malignant; Pleural Neoplasms; Radiotherapy, Intensity-Modulated
PubMed: 32088429
DOI: 10.1016/j.prro.2020.02.007 -
Expert Review of Respiratory Medicine Aug 2017Malignant pleural mesothelioma (MPM) is an aggressive neoplasia. Multidisciplinary treatments, including the association of induction and/or adjuvant therapeutic... (Review)
Review
Malignant pleural mesothelioma (MPM) is an aggressive neoplasia. Multidisciplinary treatments, including the association of induction and/or adjuvant therapeutic regimens with surgery, have been reported to give encouraging results. Current therapeutic options are not well standardized yet, especially regarding the best association between surgery and medical treatments. The present review aims to assess safety, efficacy and outcomes of different therapies for MPM. Areas covered: This article focuses on the multimodality treatment of mesothelioma. A systematic review was performed by using electronic databases to identify studies that considered induction and adjuvant approaches in MPM therapy in a multidisciplinary setting, including surgery. Endpoints included overall survival, disease free survival, disease recurrence, and complications. Expert commentary: This systematic review offers a comprehensive view of current multidisciplinary therapeutic strategies for MPM, suggesting that multimodality therapy offers acceptable outcomes with better results reported for trimodality approaches. Individualization of care for each patient is fundamental in choosing the most appropriate treatment. The growing complexity of treatment protocols mandates that MPM patients be referred to specialized Centers, in which every component of the interdisciplinary team can provide the necessary expertise and quality of care.
Topics: Antineoplastic Combined Chemotherapy Protocols; Chemotherapy, Adjuvant; Combined Modality Therapy; Humans; Induction Chemotherapy; Lung Neoplasms; Mesothelioma; Mesothelioma, Malignant; Patient Safety; Pleural Neoplasms; Pneumonectomy; Radiotherapy, Adjuvant; Treatment Outcome
PubMed: 28580813
DOI: 10.1080/17476348.2017.1338951 -
Annals of Thoracic and Cardiovascular... Dec 2022The best treatment strategy for primary spontaneous pneumothorax is controversial and varies widely in practice. (Meta-Analysis)
Meta-Analysis
PURPOSE
The best treatment strategy for primary spontaneous pneumothorax is controversial and varies widely in practice.
METHODS
Literatures were searched from databases till 24 August 2021. A Bayesian network meta-analysis was conducted to compare the outcomes of various treatments with the following endpoints: recurrence rate, postoperative chest tube duration, postoperative air leakage duration, length of hospital stay, and complications rate.
RESULTS
In all, 7210 patients of 20 randomized controlled trials and 17 cohort studies were included. Surgery had a significantly lower recurrence rate compared to other treatments. Besides, bullectomy (BT) combined with chemical pleurodesis (CP), mechanical pleurodesis, or staple line coverage (SLC) can reduce the recurrence rate compared to BT alone, but none of them were statistically significant. In terms of reducing chest tube duration, BT with tubular Neoveil outperformed BT + pleural abrasion (mean difference [MD], 95% confidence interval [CI]: -2.5 [-4.63, -0.35]) and BT + apical pleurectomy (MD, 95% CI: -2.72 [-5.16, -0.27]).
CONCLUSIONS
Surgical methods were superior to manual aspiration (MA), chest tube drainage (CTD), and conservative treatment in terms of recurrence reduction. There was no significant difference between MA and CTD in reducing the recurrence rate. Among surgical methods, CP is more effective than mechanical pleurodesis and SLC among the additional procedures based on BT.
Topics: Humans; Pneumothorax; Network Meta-Analysis; Bayes Theorem; Treatment Outcome; Recurrence; Pleurodesis; Thoracic Surgery, Video-Assisted
PubMed: 36002271
DOI: 10.5761/atcs.oa.22-00113 -
Respirology (Carlton, Vic.) Oct 2014Yellow nail syndrome (YNS) can be associated with a pleural effusion (PE) but the characteristics of these patients are not well defined. We performed a systematic... (Review)
Review
Yellow nail syndrome (YNS) can be associated with a pleural effusion (PE) but the characteristics of these patients are not well defined. We performed a systematic review across four electronic databases for studies reporting clinical findings, PE characteristics, and most effective treatment of YNS. Case descriptions and retrospective studies were included, unrestricted by year of publication. We reviewed 112 studies (150 patients), spanning a period of nearly 50 years. The male/female ratio was 1.2/1. The median age was 60 years (range: 0-88). Seventy-eight percent were between 41-80 years old. All cases had lymphoedema and 85.6% had yellow nails. PEs were bilateral in 68.3%. The appearance of the fluid was serous in 75.3%, milky in 22.3% and purulent in 3.5%. The PE was an exudate in 94.7% with lymphocytic predominance in 96% with a low count of nucleated cells. In 61 of 66 (92.4%) of patients, pleural fluid protein values were >3 g/dL, and typically higher than pleural fluid LDH. Pleurodesis and decortication/pleurectomy were effective in 81.8% and 88.9% of cases, respectively, in the treatment of symptomatic PEs. The development of YNS and PE occurs between the fifth to eighth decade of life and is associated with lymphoedema. The PE is usually bilateral and behaves as a lymphocyte-predominant exudate. The most effective treatments appear to be pleurodesis and decortication/pleurectomy.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Child, Preschool; Female; Humans; Infant; Infant, Newborn; Male; Middle Aged; Pleural Effusion; Yellow Nail Syndrome; Young Adult
PubMed: 25123563
DOI: 10.1111/resp.12357 -
Thoracic Surgery Clinics Nov 2020Despite multiple diagnostic toolkits, the diagnosis of diffuse malignant pleural mesothelioma relies primarily on proper histologic assessment. The definitive diagnosis...
Despite multiple diagnostic toolkits, the diagnosis of diffuse malignant pleural mesothelioma relies primarily on proper histologic assessment. The definitive diagnosis of diffuse malignant pleural mesothelioma is based on the pathologic assessment of tumor tissue, which can be obtained from core biopsy sampling, pleurectomy, or other more extensive resections, such as extrapleural pneumonectomy. Given its rarity and overlapping microscopic features with other conditions, the histologic diagnosis of diffuse malignant pleural mesothelioma is challenging. This review discusses the pathologic features and the differential diagnosis of diffuse malignant pleural mesothelioma, including select diagnostic pitfalls.
Topics: Biopsy; Diagnosis, Differential; Humans; Mesothelioma, Malignant; Pleural Neoplasms; Thoracic Surgical Procedures
PubMed: 33012427
DOI: 10.1016/j.thorsurg.2020.08.007 -
Journal of Clinical Medicine Jun 2022Malignant pleural mesothelioma (MPM) is an aggressive asbestos-related tumour with poor prognosis. To date, a multimodality treatment, including chemotherapy and... (Review)
Review
Malignant pleural mesothelioma (MPM) is an aggressive asbestos-related tumour with poor prognosis. To date, a multimodality treatment, including chemotherapy and surgery, with or without radiotherapy, is the gold standard therapy for selected patients with epithelioid and early-stage MPM. In this setting, the goal of surgery is to achieve the macroscopic complete resection, obtained by either extrapleural pneumonectomy or pleurectomy/decortication. Failure, in local and/or distant sites, is one of the major concerns; in fact, there has been no established treatment for the recurrence of MPM after the multimodal approach, and the role of surgery in this context is still controversial. By using electronic databases, studies that included recurrent MPM patients who underwent a second surgery were identified. The endpoints included were: a pattern of recurrence, post-recurrence survival (PRS), and the type of second surgery. When available, factors predicting better PRS and perioperative mortality and morbidity were collected. This systematic review offers an overview of the results that are currently obtained in patients undergoing a second surgery for relapsed MPM, with the aim to provide a comprehensive view on this subject that explores if a second surgery leads to an improvement in survival.
PubMed: 35743417
DOI: 10.3390/jcm11123340