The surgical-based treatment of malignant pleural mesothelioma: a literature review of a still ongoing debate

doi:10.3877/cma.j.issn.2095-8773.2022.04.01

Background and Objective:

Pleural mesothelioma is an aggressive disease with poor prognosis due to the tendency to relapse. Despite the lack of uniform protocols of therapy, surgery remains the cornerstone of multimodal treatment. Nevertheless, the debate on which is the optimal choice for surgical-based approach lasts over time and is based over the oncological benefits of obtaining a theoretical greater radicality rather than preserving the anatomical integrity in view of further treatments. This review is intended to summarize the topics of this dispute still ongoing.

Methods:

A review on the PubMed/Medline literature database of the different surgical approach was carried out, screening all the publications in English from 2000 to 2021. The search strategy has been focused on comparative studies of surgical techniques to understand if and how the choice of the type of surgery to be offered in the forefront has changed over the years.

Key Content and Findings:

Within the multimodal strategy the goal of surgery, performed with radical intent, is to achieve the macroscopic complete removal. Two procedures are aimed to this purpose: the lung-sacrificing surgery as the extrapleural pneumonectomy and the lung-sparing surgery as the pleurectomy/decortication extended or not to resection/reconstruction of diaphragm and pericardium. Many centers today have abandoned the most radical procedure in favor of the most conservative, but the superiority of one technique over the other remains controversial.

Conclusions:

In the absence of comparative randomized trials, the choice of surgical technique is determined by the experience of individual centers and by the attitude of surgeons. Further research is needed to standardize treatment protocols and to define the role of surgery in the context of multimodal therapy.

关键词: Pleural mesothelioma, pleurectomy/decortication, lung-sparing surgery, extrapleural pneumonectomy

Background and Objective:

Methods:

Key Content and Findings:

Conclusions:

Key words: Pleural mesothelioma, pleurectomy/decortication, lung-sparing surgery, extrapleural pneumonectomy

Figure 1 Algorithm of search strategy and study selection.

Table 1 Search strategy summary

Items	Specification
Date of Search	January 2021
Databases and other sources searched	Medline/PubMed resources
Search terms used (including MeSH and free text search terms and filters)	Search: pleurectomy extrapleural pneumonectomy mesothelioma Filters: English, from 2000-2021; search: lung-sparing mesothelioma Filters: English, from 2000-2021
Timeframe	From 2000 to 2021
Inclusion and exclusion criteria (study type, language restrictions etc.)	Filters for research: language, timeframe; inclusion criteria: all publications dealing with surgical treatment of MPM especially if focused on the comparison between the different techniques; exclusion criteria: Case Report, articles about modalities of treatment different from surgery
Selection process (who conducted the selection, whether it was conducted independently, how consensus was obtained, etc.)	All authors were involved in the selection process. The screening of the publication was conducted independently by each. Agreement has been reached on the basis of shared choice criteria

Table 1 Search strategy summary

Items	Specification
Date of Search	January 2021
Databases and other sources searched	Medline/PubMed resources
Search terms used (including MeSH and free text search terms and filters)	Search: pleurectomy extrapleural pneumonectomy mesothelioma Filters: English, from 2000-2021; search: lung-sparing mesothelioma Filters: English, from 2000-2021
Timeframe	From 2000 to 2021
Inclusion and exclusion criteria (study type, language restrictions etc.)	Filters for research: language, timeframe; inclusion criteria: all publications dealing with surgical treatment of MPM especially if focused on the comparison between the different techniques; exclusion criteria: Case Report, articles about modalities of treatment different from surgery
Selection process (who conducted the selection, whether it was conducted independently, how consensus was obtained, etc.)	All authors were involved in the selection process. The screening of the publication was conducted independently by each. Agreement has been reached on the basis of shared choice criteria

Table 2 Comparative studies on outcomes: lung-sparing vs. lung-sacrificing surgery

Study	Multimodal treatment	(E)P/D		EPP
Study	Multimodal treatment	30-day mortality/OM	Survival (months)	30-day mortality/OM	Survival (months)
Flores^[38], 2007	Mixed	3%	15.8	5%	14.3
Schipper^[39], 2008	Mixed	0%/20%; total pleurectomy	17.2; total pleurectomy	8.2%/50.7%	16
Flores^[40], 2008	+/− ind CT; +/− adj RT; +/− other	4%/6.4%	16	7%/10%	12
Okada^[41], 2008	Mixed	0%	17	1.5%	13
Luckraz^[42], 2010	+/− adj CT; +/− adj RT	2.2%/16%	Not Reported	10.2%/41%	Not reported
Friedberg^[30], 2011	Mixed	0%; radical pleurectomy	Not reached	2%	8.4
Rena^[43], 2012	Mixed	0%/24%	32	5%/62%	28
Nakas^[44], 2012	Mixed	3%/43%	13.4	7%/68%	14.7
Lang-Lazdunski^[45], 2012	Mixed	0%/27.7%	23	4.5%/68%	12.8
Bedirhan^[46], 2013	Adj CT; +/− adj RT	P/D 30-day: 4%; EP/D 30-day: 0%	P/D 15 EP/D 27	30-day: 12.9%	17
Bovolato^[47], 2014	+/− CT	2.6%/10.4%	20.5	4.1%/21.6%	18.8
Infante^[37], 2016	+/− CT; +/− adj RT	2.1%/26%	30	3.3%/27%	19
Sharkey^[48], 2016	Mixed	3.5%/NR	12.3	6%/NR	12.9
Kostron^[49], 2017	Ind CT; +/− adj RT	0%/58%	32	5%/38%	23
Miyazaki^[21], 2018	Mixed	0%/44%	22.5	0%/33%	16.5
Hasegawa^[50], 2019	Ind CT; +/− adj RT	1.6%/29%	43.4	3.8%/46.2%	18.5
Zhou^[51], 2022	+/− ind CT; +/− adj RT	30-day: 0%	18	30-day: 11%	11

Table 2 Comparative studies on outcomes: lung-sparing vs. lung-sacrificing surgery

Study	Multimodal treatment	(E)P/D		EPP
Study	Multimodal treatment	30-day mortality/OM	Survival (months)	30-day mortality/OM	Survival (months)
Flores^[38], 2007	Mixed	3%	15.8	5%	14.3
Schipper^[39], 2008	Mixed	0%/20%; total pleurectomy	17.2; total pleurectomy	8.2%/50.7%	16
Flores^[40], 2008	+/− ind CT; +/− adj RT; +/− other	4%/6.4%	16	7%/10%	12
Okada^[41], 2008	Mixed	0%	17	1.5%	13
Luckraz^[42], 2010	+/− adj CT; +/− adj RT	2.2%/16%	Not Reported	10.2%/41%	Not reported
Friedberg^[30], 2011	Mixed	0%; radical pleurectomy	Not reached	2%	8.4
Rena^[43], 2012	Mixed	0%/24%	32	5%/62%	28
Nakas^[44], 2012	Mixed	3%/43%	13.4	7%/68%	14.7
Lang-Lazdunski^[45], 2012	Mixed	0%/27.7%	23	4.5%/68%	12.8
Bedirhan^[46], 2013	Adj CT; +/− adj RT	P/D 30-day: 4%; EP/D 30-day: 0%	P/D 15 EP/D 27	30-day: 12.9%	17
Bovolato^[47], 2014	+/− CT	2.6%/10.4%	20.5	4.1%/21.6%	18.8
Infante^[37], 2016	+/− CT; +/− adj RT	2.1%/26%	30	3.3%/27%	19
Sharkey^[48], 2016	Mixed	3.5%/NR	12.3	6%/NR	12.9
Kostron^[49], 2017	Ind CT; +/− adj RT	0%/58%	32	5%/38%	23
Miyazaki^[21], 2018	Mixed	0%/44%	22.5	0%/33%	16.5
Hasegawa^[50], 2019	Ind CT; +/− adj RT	1.6%/29%	43.4	3.8%/46.2%	18.5
Zhou^[51], 2022	+/− ind CT; +/− adj RT	30-day: 0%	18	30-day: 11%	11

Table 3 Comparative studies on recurrence: lung-sparing vs. lung-sacrificing surgery

Study	n	Median OS (months)	Median DFS (months)	Median PRS (months)
Kai et al.^[56], 2019	EPP: 29; P/D: 15	Overall: 22; EPP: 17; P/D: 34*	Overall: 14; EPP: 13; P/D: 21*	Overall: 5; EPP: 3; P/D: 20*
Bellini et al.^[53], 2021	EPP: 49; P/D: 45	Overall: 33; EPP: 38; P/D: 23	Overall: 14; EPP: 20; P/D: 11	Overall: 12; EPP: 14; P/D: 8

Table 3 Comparative studies on recurrence: lung-sparing vs. lung-sacrificing surgery

Study	n	Median OS (months)	Median DFS (months)	Median PRS (months)
Kai et al.^[56], 2019	EPP: 29; P/D: 15	Overall: 22; EPP: 17; P/D: 34*	Overall: 14; EPP: 13; P/D: 21*	Overall: 5; EPP: 3; P/D: 20*
Bellini et al.^[53], 2021	EPP: 49; P/D: 45	Overall: 33; EPP: 38; P/D: 23	Overall: 14; EPP: 20; P/D: 11	Overall: 12; EPP: 14; P/D: 8

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