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Cancers Apr 2024Surgery plays a central role in the diagnosis, staging, and management of pleural mesothelioma. Achieving an accurate diagnosis through surgical intervention and... (Review)
Review
Surgery plays a central role in the diagnosis, staging, and management of pleural mesothelioma. Achieving an accurate diagnosis through surgical intervention and identifying the specific histologic subtype is crucial for determining the appropriate course of treatment. The histologic subtype guides decisions regarding the use of chemotherapy, immunotherapy, or multimodality treatment. The goal of surgery as part of multimodality treatment is to accomplish macroscopic complete resection with the eradication of grossly visible and palpable disease. Over the past two decades, many medical centers worldwide have shifted from performing extra-pleural pneumonectomy (EPP) to pleurectomy decortication (PD). This transition is motivated by the lower rates of short-term mortality and morbidity associated with PD and similar or even better long-term survival outcomes, compared to EPP. This review aims to outline the role of surgery in diagnosing, staging, and treating patients with pleural mesothelioma.
PubMed: 38730667
DOI: 10.3390/cancers16091719 -
Turk Gogus Kalp Damar Cerrahisi Dergisi Jul 2023This study aims to evaluate overall survival, diseasefree survival, and prognostic factors in patients undergoing pleurectomy-decortication and hyperthermic...
BACKGROUND
This study aims to evaluate overall survival, diseasefree survival, and prognostic factors in patients undergoing pleurectomy-decortication and hyperthermic intrathoracic chemotherapy with the diagnosis of malignant pleural mesothelioma.
METHODS
Between January 2020 and November 2021, a total of 53 patients (27 males, 26 females; mean age: 58.1±1.3 years; range, 39 to 81 years) who underwent pleurectomy-decortication and hyperthermic intrathoracic chemotherapy with the diagnosis of malignant pleural mesothelioma were retrospectively analyzed. Data including characteristics, comorbidities, postoperative complications, recurrence and mortality status of the patients were recorded. Overall survival and disease-free survival and prognostic factors were evaluated.
RESULTS
The median disease-free survival was 11.67 months and the median overall survival was 24.60 months. The median disease-free survival was 8.80 months in men and 13.17 months in women, indicating a statistically significant difference as it showed that recurrence was detected earlier in male patients (p=0.037). The median disease-free survival and overall survival was 6.13 months and 11.70 in cases diagnosed with biphasic mesothelioma, respectively, while it was 11.67 months and 25.46 months in cases with epithelial mesothelioma, respectively. Pathological subtype was found to be an effective prognostic factor for both survival (p=0.049 and p<0.001, respectively).
CONCLUSION
Hyperthermic intrathoracic chemotherapy following cytoreductive surgery is a preferable and tolerable method in the treatment of malignant pleural mesothelioma. While evaluating surgical indications, it should be kept in mind that cases with epithelial mesothelioma may benefit more from surgical treatment.
PubMed: 37664769
DOI: 10.5606/tgkdc.dergisi.2023.24329 -
Thoracic Cancer May 2024Tumor recurrence remains the main barrier to survival after surgery for pleural mesothelioma (PM). Soluble mesothelin-related protein (SMRP) and cancer antigen 125...
BACKGROUND
Tumor recurrence remains the main barrier to survival after surgery for pleural mesothelioma (PM). Soluble mesothelin-related protein (SMRP) and cancer antigen 125 (CA-125) are established blood-based biomarkers for monitoring PM. We prospectively studied the utility of these biomarkers after pleurectomy decortication (PD).
METHODS
Patients who underwent PD and achieved complete macroscopic resection with available preoperative SMRP levels were included. Tumor marker levels were determined within 60 days of three timepoints: (1) preoperation, (2) post-operation, and (3) recurrence.
RESULTS
Of 356 evaluable patients, 276 (78%) had recurrence by the end of follow-up interval. Elevated preoperative SMRP levels were associated with epithelioid histology (p < 0.013), advanced TNM (p < 0.001) stage, and clinical stage (p < 0.001). Preoperative CA-125 levels were not significantly associated with clinical covariates. Neither biomarker was associated with survival or disease-free survival. With respect to nonpleural and nonlymphatic recurrences, mean SMRP levels were elevated in patients with pleural (p = 0.021) and lymph node (p = 0.042) recurrences. CA-125 levels were significantly higher in patients with abdominal (p < 0.001) and lymph node (p = 0.004) recurrences. Among patients with all three timepoints available, we observed an average decrease in SMRP levels by 1.93 nmol/L (p < 0.001) postoperatively and again an average increase at recurrence by 0.79 nmol/L (p < 0.001). There were no significant changes in levels of CA-125 across the study timepoints (p = 0.47).
CONCLUSIONS
Longitudinal changes in SMRP levels corresponded with a radiographic presence of disease in a subset of patients. SMRP surveillance could aid in detection of local recurrences, whereas CA-125 could be helpful in recognizing abdominal recurrences.
Topics: Humans; Male; Female; CA-125 Antigen; Aged; Pleural Neoplasms; Middle Aged; Biomarkers, Tumor; Mesothelioma; Neoplasm Recurrence, Local; Mesothelin; Mesothelioma, Malignant; Prospective Studies; Adult; Aged, 80 and over; GPI-Linked Proteins; Lung Neoplasms
PubMed: 38627917
DOI: 10.1111/1759-7714.15264 -
Thoracic Cancer Sep 2023Pleurectomy and decortication (PD) in malignant pleural mesothelioma has a high morbidity mostly associated with aspiration pneumonia (PNA), deep vein thrombosis (DVT),...
BACKGROUND
Pleurectomy and decortication (PD) in malignant pleural mesothelioma has a high morbidity mostly associated with aspiration pneumonia (PNA), deep vein thrombosis (DVT), and foreign catheter sepsis. We instituted four strategies to reduce these complications and report our experience.
METHODS
This was a retrospective review of patients who underwent PD at the University of Pennsylvania between 2015 and 2022. Our patients underwent standard of care PD in addition to tracheostomy and gastrostomy/jejunostomy tube with therapeutic anticoagulation (AC) leading up to surgery. Measured outcomes were postoperative PNA, DVT, and sepsis. The predicted risk of those same outcomes had patients not undergone the interventions was calculated based on the American College of Surgeons (ACS) surgical risk calculator (SRC). A McNemar's test was used to determine whether the risk of having PNA, DVT and sepsis differed between the two subgroups.
RESULTS
Fifty-five patients were included in the study. The mean age was 70 years (SD 6.2) with a mean of 21 (SD 19) pack-years of smoking. PNA, DVT, and catheter-related sepsis occurred in 12, four, and seven patients, respectively. Upon using the ACS SRC prediction model of the nonintervention group, PNA, DVT and catheter related sepsis was predicted to occur in 24 (paired data OR 5, 95% CI: 1.4-17.2; McNemar's test p = 0.008), 14 (paired data OR 3.5, 95% CI: 1.15-10.6; McNemar's test p = 0.03), and 17 (paired OR 3, 95% CI: 1.09-8.3; McNemar's test p = 0.04) patients, respectively.
DISCUSSION
Patients undergoing tracheostomy creation, therapeutic AC at the time of diagnosis, and gastrostomy tube placement had a reduced risk of aspiration PNA, DVT, and catheter sepsis.
Topics: Humans; Aged; Mesothelioma, Malignant; Mesothelioma; Pleural Neoplasms; Lung Neoplasms; Treatment Outcome; Morbidity; Sepsis
PubMed: 37574596
DOI: 10.1111/1759-7714.15067 -
JTCVS Open Dec 2023To evaluate the efficacy of multimodality treatment including extended pleurectomy/decortication (P/D) and hyperthermic intraoperative chemotherapy (HIOC) with cisplatin...
OBJECTIVE
To evaluate the efficacy of multimodality treatment including extended pleurectomy/decortication (P/D) and hyperthermic intraoperative chemotherapy (HIOC) with cisplatin for malignant pleural mesothelioma (MPM), we investigated the pharmacokinetics of platinum, adverse events after HIOC, and survival outcome.
METHODS
Fifty-three patients with pathologically diagnosed MPM (cT1-3N0-1M0, excluding sarcomatoid) underwent an extended P/D and HIOC (cisplatin 80 mg/m in saline 2 L, 42°C, 60 minutes) since 2011. The protocol includes postoperative 4 cycles of cisplatin and pemetrexed. Platinum concentrations in the perfusate (before and after) and the serum (1, 2, 4, 8, 24, 48, 72 hours after perfusion) were measured in 10 patients. Mortality and morbidity, especially adverse events of renal function, were investigated, and survival and affecting factors were examined.
RESULTS
All patients obtained macroscopic complete resection and pathologic staging revealed as follows: T1/2/3/4: 12/8/23/10, N0/1: 36/17, stage 1A/1B-3A/3B: 12/31/10, respectively. Platinum concentrations in the perfusate indicated that 28% of the dose remained in the pleural cavity, and the maximum concentration in the serum was 0.91 μg/mL. Six patients (11%) showed elevated max-creatinine (>2 mg/dL) postoperatively. Two patients (4%) received renal-replacement therapy, and one was weaned before discharge. There was no 30-day mortality and one in-hospital death (1.9%). Forty-six patients (87%) received multiple cycles of perioperative systemic chemotherapy. Median overall survival (OS) and disease-free survival (DFS) were 52.4 months and 18.7 months. Patents with stage 1A demonstrated a 5-year OS of 67.3% and a median DFS of 67.1 months, and patients with stage 1B-3A demonstrated a 5-year OS of 50.1% and a median DFS of 20.4 months. Univariate analysis showed histological subtype, p-T, p-stage, and multimodality treatment as significant factors affecting OS. Multivariate analysis revealed histology, p-stage, and multimodality as independent.
CONCLUSIONS
Extended P/D and HIOC with cisplatin for MPM is acceptable with limited acute kidney injury. This multimodality protocol provides promising favorable survival for stage 1A-3A disease.
PubMed: 38204668
DOI: 10.1016/j.xjon.2023.09.005 -
BMJ Open May 2024Extrapleural pneumonectomy (EPP) and extended pleurectomy/decortication (ePD) are surgical cytoreductive techniques aimed at achieving macroscopic resection in malignant... (Review)
Review
INTRODUCTION
Extrapleural pneumonectomy (EPP) and extended pleurectomy/decortication (ePD) are surgical cytoreductive techniques aimed at achieving macroscopic resection in malignant pleural tumours such as pleural mesothelioma, non-mesothelioma pleural malignancies such as thymoma and sarcoma, and rarely for pleural tuberculosis, in a more limited fashion. Despite extensive studies on both surgical techniques and consequences, a significant knowledge gap remains regarding how best to approach the perioperative anaesthesia challenges for EPP and ePD.It is unknown if the risk stratification processes for such surgeries are standardised or what types of functional and dynamic cardiac and pulmonary tests are employed preoperatively to assist in the perioperative risk stratification. Further, it is unknown whether the types of anaesthesia and analgesia techniques employed, and the types of haemodynamic monitoring tools used, impact on outcomes. It is also unknown whether individualised haemodynamic protocols are used to guide the rational use of fluids, vasoactive drugs and inotropes.Finally, there is a dearth of evidence regarding how best to monitor these patients postoperatively or what the most effective enhanced recovery protocols are to best mitigate postoperative complications and accelerate hospital discharge. To increase our knowledge of the perioperative and anaesthetic treatment for patients undergoing EPP/ePD, this scoping review attempts to synthesise the literature and identify these knowledge gaps.
METHODS AND ANALYSIS
This scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Review Protocols methodology. Electronic databases, OVID Medline, EMBASE and the Cochrane Library, will be systematically searched for relevant literature corresponding to EPP or ePD and perioperative or anaesthetic management. Data will be analysed and summarised descriptively and organised according to the three perioperative stages: preoperative, intraoperative and postoperative factors in clinical care.
ETHICS AND DISSEMINATION
Ethics approval was not required. The findings will be disseminated through professional networks, conference presentations and publications in scientific journals.
Topics: Humans; Pneumonectomy; Anesthesia; Pleura; Perioperative Care; Pleural Neoplasms; Postoperative Complications
PubMed: 38760041
DOI: 10.1136/bmjopen-2023-078125 -
Journal of Thoracic Disease Jul 2023An optimal surgical procedure for primary spontaneous pneumothorax (PSP) has not yet been established. The study aimed to compare patient-reported outcomes (PROs) and...
Comparison of patient-reported outcomes and clinical outcomes between pleurectomy and pleural covering added to thoracoscopic bullectomy for primary spontaneous pneumothorax.
BACKGROUND
An optimal surgical procedure for primary spontaneous pneumothorax (PSP) has not yet been established. The study aimed to compare patient-reported outcomes (PROs) and clinical outcomes between parietal pleurectomy (pleurectomy) and visceral pleural covering with absorbable prosthesis (covering) added to thoracoscopic bullectomy in patients with PSP.
METHODS
From January 2015 to April 2018, PROs were prospectively evaluated using EuroQOL-5 dimensions-5 levels (EQ5D). Questionnaires were administered preoperatively and at 1, 3, and 5 days and 1 month postoperatively. The perioperative outcomes were compared retrospectively. Recurrences and postoperative symptoms in the distant period were investigated cross-sectionally by telephone and mail surveys in February 2020.
RESULTS
In total, 26 and 29 patients underwent covering and pleurectomy, respectively. The visual analog scale score of the EQ5D on postoperative day 1 was significantly better in the pleurectomy group than in the covering group. There was no significant difference in the frequency of PROs in the EQ5D including pain. Perioperative outcomes, such as postoperative chest tube placement, and hospital stay, were comparable between the groups, except for the operative time. There was no significant difference in the recurrence rate and frequency of residual symptoms, e.g., chest discomfort in the long-term outcomes.
CONCLUSIONS
PROs and clinical outcomes were comparable between the two procedures. Further studies are required to determine the optimal treatment procedure.
PubMed: 37559634
DOI: 10.21037/jtd-23-214 -
Ulusal Travma Ve Acil Cerrahi Dergisi =... Aug 2023Pneumothorax in patients with underlying lung pathology is called secondary spontaneous pneumothorax (SSP). It is an important health problem worldwide, with significant...
BACKGROUND
Pneumothorax in patients with underlying lung pathology is called secondary spontaneous pneumothorax (SSP). It is an important health problem worldwide, with significant morbidity, high health-care expenses, and possibility of mortality. This study aimed to evaluate the epidemiological characteristics, risk factors for mortality and morbidity, and treatment options of SSP.
METHODS
Outcomes of 133 patients with SSP were evaluated retrospectively. Patients with SP with evidence of underlying lung disease or a smoking history over 50 years of age were considered SSP. The patients were analyzed in terms of epidemiological fea-tures, underlying diseases, treatment methods, complications, and mortality. The treatment options included thoracotomy (T), video-assisted thoracoscopic surgery (VATS), tube thoracostomy, and conservative treatment.
RESULTS
The mean age was 50.50±20.374 years, and the age range was 16-95. Ninety-three (69.9%) of the patients were smokers. The most common clinical finding was dyspnea in 77 (57.9%) patients. The most common underlying disease was chronic obstructive pulmonary disease in 62 patients (46.6%). Six (4.5%) patients received conservative treatment, a chest tube was placed in 89 (66.9%) patients, and 38 (28.6%) patients were treated with surgery. As an operative procedure, lung wedge resection was performed in 24 (18.0%) patients and bulla resection was performed in 6 (4.5%) patients. Parietal pleurectomy was performed in 27 (20.3%) patients. Axillary mini-T or T was performed more frequently in large pneumothorax, smokers, and in obstructive pulmonary disease. Tube thoracostomy was used more frequently in poor physical performance, comorbidities, and infectious diseases. Complications were ob-served in 55 patients (41.4%). The most common complication was persistent air leakage in 18 (13.5%) patients. Complications were associated with large pneumothorax (P=0.003), poor physical performance (P=0.009), infectious diseases (P= 0.030), and occupational risk factors (P=0.032). Recurrence was developed in 12 (9.0%) patients. Postoperative recurrence was observed in 1 patient. Four (3%) patients died. Mortality was higher in patients with poor physical performance (P=0.027), comorbidities (P=0.008), and patients with complications (P=0.027). The length of stay in the hospital was high in mini-axillary T (AT)/T (P<0.001) and VATS (P<0.001). There was no significant relationship between the mini-AT/T and VATS in terms of length of hospital stay.
CONCLUSION
Large pneumothorax, poor physical performance, and comorbidity are associated with morbidity and mortality. Conservative treatment for small pneumothorax and chest tube for large pneumothorax is the most appropriate initial treatment. Resection of the bullous region through VATS or mini-AT/T is the most appropriate surgical technique.
Topics: Humans; Middle Aged; Adult; Aged; Pneumothorax; Retrospective Studies; Thoracic Surgery, Video-Assisted; Thoracotomy; Morbidity; Recurrence; Treatment Outcome
PubMed: 37563896
DOI: 10.14744/tjtes.2023.20566 -
Cancer Science Feb 2024Due to the scarcity of large-sized prospective databases, the Japanese Joint Committee for Lung Cancer Registry conducted a nationwide prospective registry for newly...
Due to the scarcity of large-sized prospective databases, the Japanese Joint Committee for Lung Cancer Registry conducted a nationwide prospective registry for newly diagnosed and untreated pleural mesothelioma. All new cases diagnosed pathologically as any subtype of pleural mesothelioma in Japan during the period between April 1, 2017, to March 31, 2019, were included before treatment. Data on survival were collected in April 2021. The eligible 346 patients (285 men [82.3%]; 61 women [17.7%]; median age, 71.0 years [range, 44-88]) were included for analysis. Among these patients, 138 (39.9%) underwent surgery, 164 (47.4%) underwent non-surgical therapy, and the remaining 44 (12.7%) underwent best supportive care. The median overall survival for all 346 patients was 19.0 months. Survival rates at 1, 2, and 3 years for all patients were, 62.8%, 42.3%, and 26.5%, respectively. Median overall survival was significantly different among patients undergoing surgery, non-surgical treatment, and best supportive care (32.2 months vs. 14.0 months vs. 3.8 months, p < 0.001). The median overall survival of patients undergoing pleurectomy/decortication and extrapleural pneumonectomy was 41.8 months and 25.0 months, respectively. Macroscopic complete resection resulted in longer overall survival than R2 resection and partial pleurectomy/exploratory thoracotomy (41.8 months vs. 32.2 months vs. 16.8 months, p < 0.001). Tumor shape, maximum tumor thickness, and sum of three level thickness were significant prognostic factors. The data in the prospective database would serve as a valuable reference for clinical practice and further studies for pleural mesothelioma.
Topics: Male; Humans; Female; Aged; Japan; Treatment Outcome; Mesothelioma, Malignant; Mesothelioma; Pleural Neoplasms; Lung Neoplasms; Retrospective Studies
PubMed: 38047872
DOI: 10.1111/cas.16021 -
Cureus Mar 2024The presented case describes a 56-year-old male with adult-onset Still's disease, exhibiting polyserositis in 2019, who underwent pleurectomy and pericardiectomy....
The presented case describes a 56-year-old male with adult-onset Still's disease, exhibiting polyserositis in 2019, who underwent pleurectomy and pericardiectomy. Despite treatment with tocilizumab and methylprednisolone, the patient developed deep vein thrombosis and pulmonary embolism in 2022, managed with apixaban. A contrast-enhanced chest tomography revealed no recurrent thromboembolic events. Over a year, the patient experienced progressive dyspnea, correlating with signs of constriction on transthoracic echocardiogram. Cardiac magnetic resonance imaging confirmed cardiac herniation, prompting pericardiectomy. Surgery led to complete resolution of anatomical alterations without heart failure or new abnormalities, although exertional dyspnea persists post-discharge. The pathophysiology of cardiac herniation involves complex mechanisms influenced by congenital or acquired factors, resulting in abnormal heart protrusion. Medical literature highlights varied presentations, with acute cases typically post-thoracic surgeries, while late-onset cases are less common. Imaging modalities like computed tomography (CT) and cardiac magnetic resonance (CMR) aid diagnosis, emphasizing interdisciplinary collaboration. Despite challenges posed by its rarity, timely diagnosis and treatment are crucial for favourable outcomes, demonstrating the importance of considering this entity in clinical practice.
PubMed: 38633964
DOI: 10.7759/cureus.56339