Interact CardioVasc Thorac Surg 2009;8:454-456. doi:10.1510/icvts.2008.197160
© 2009 European Association of Cardio-Thoracic Surgery
Best evidence topic - Thoracic oncologic |
Does video-assisted thoracoscopic decortication in advanced malignant mesothelioma improve prognosis?
Vivek Srivastavaa,
Joel Dunningb,* and
John Aua
a Department of Cardiothoracic Surgery, Victoria Hospital, Blackpool, UK
b Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
Received 29 October 2008;
received in revised form 16 December 2008;
accepted 18 December 2008
*Corresponding author. Tel./fax: +447801548122.
E-mail address: joeldunning{at}doctors.org.uk (J. Dunning).
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Abstract
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A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: Does video-assisted thoracoscopic (VATS) decortication in advanced malignant mesothelioma improve prognosis? Altogether more than 25 papers were found using the reported search, of which five represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that VATS decortication is useful as a palliative measure in advanced malignant mesothelioma. VATS provides a diagnostic tool, yielding tissue for histological diagnosis. Secondly, drainage of effusion and pleurectomy/decortication improves the quality of life and may increase survival as well.
Key Words: Evidence based medicine; Mesothelioma; VATS; Survival; Prognosis
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
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2. Three-part question
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In [patients with advanced malignant mesothelioma] does [VATS decortication] improve [prognosis]?
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3. Clinical scenario
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A relative of one of your close friends is admitted to a hospital. You are requested to see this old frail man who had a large pleural effusion. The pleural effusion has been drained using an intercostal drain but the lung has failed to re-expand completely. He is suspected to have pleural mesothelioma. Your friend asks if he can have a VATS decortication. You wonder if having a VATS decortication would benefit the patient. You resolve to check the literature for evidence.
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4. Search strategy
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Medline 1950 to May 2008 using Pubmed interface [mesothelioma OR malignant mesothelioma OR pleural mesothelioma] AND [VATS OR thoracoscopic surgery OR debulking OR decortication] AND [survival OR mortality OR palliation OR quality of life].
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5. Search outcome
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Twenty-five papers were found using the reported search. From these five papers were identified that provided the best evidence to answer the question. These are presented in Table 1.
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6. Results
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Nakas et al. [2] studied 208 patients having a therapeutic intervention for mesothelioma over a 9-year period. Of these, 67 had VATS decortication while the rest had non-VATS intervention. These included 112 patients undergoing extrapleural pneumonectomy (EPP) and 29 with open pleurectomy/decortication (P/D). They found that overall mean survival in the VATS group was 14 months while in the EPP group, it was 11.5 months, P=0.6. However, when they compared the 30-day mortality in patients >65 years old, they found that in the VATS group it was 7.1% compared to that in EPP group (23%) and the P/D group (12.5%). Fourteen patients (58%) had significant improvement in pain and 20 patients (83%) had improvement in dyspnea following VATS P/D. They concluded in view of similar survival rates in the three groups that VATS should be used for palliation in the selected group of patients >70 years old.
Halstead et al. [3] studied 79 patients with advanced malignant pleural mesothelioma (MPM), 28 of which had VATS biopsy while 51 had VATS pleurectomy/decortication. The actuarial survival in the P/D group was 416 days vs. 127 days in the biopsy alone group, P<0.001. The duration of hospital stay and the incidence of air leaks was significantly more in the P/D group. They concluded that VATS P/D was feasible in the majority of patients and improved survival in advanced MPM.
Martin-Ucar et al. [4] made a prospective cohort study involving 51 patients with advanced malignant mesothelioma undergoing palliative treatment. A total of 20 patients in this study had VATS intervention. Seventeen (34%) had VATS subtotal parietal pleurectomy while three patients had VATS parietal and visceral decortication. Overall, 31 patients had parietal/visceral decortication by thoracotomy. Overall survival was 89% at 6 weeks, 71% at 3 months, 56% at 6 months and 31% at 12 months. The type of procedure did not significantly influence survival. This study concluded that debulking surgery is beneficial in palliation of unresectable malignant mesothelioma. It should be reserved for epithelial cell type before significant loss of weight in whom it provided for better survival and symptom control.
Grossebner et al. [5] did a prospective study on 25 patients who were referred for histological diagnosis by VATS. Malignant mesothelioma was confirmed in 23 of them. These also had drainage of effusion, cytoreductive pleurectomy and lung mobilisation by VATS. Fifteen patients could achieve closure of the pleural space of which 11 patients were alive at 1–2 years. One-year survival in this group was thus 73.3%. Pleural space could not be closed in six patients. Of this group, five patients died in 5–6 months and one patient survived nine months. Thus the survival at six months in this group was only 16.6%. They concluded that VATS was useful in terms of providing adequate tissue for a histological diagnosis and also therapeutic intervention. Further, that there were fewer hospital readmissions and better quality of life when the pleural space could be closed. However, the incidence of postoperative air leaks in this group was greater and led to a longer hospital stay initially.
Waller et al. [6] studied 19 patients with malignant pleural effusion. Thirteen of these had malignant mesothelioma, six had metastatic adenocarcinoma. These underwent parietal pleurectomy by VATS. Median postoperative stay was 5 days (range 2–20 days). At a median follow-up of 12 months, six patients had died of underlying disease (median of 4 months, range 2–8 months) – 2 of these had mesothelioma. Tumour seeding at the port site developed in five patients, all of whom had mesothelioma and two of which had died. They concluded that VATS parietal pleurectomy was a safe and effective palliative measure if the visceral pleura was not heavily involved and the lung was not entrapped. This study did not give separate mortality/survival statistics for mesothelioma compared to other causes of malignant pleural effusion.
All these papers are prospective cohort studies, level 2b and there have been no randomised controlled trials. Also, the form in which the data has been presented in the various papers is not uniform and hence it is not possible to draw a definitive conclusion.
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7. Clinical bottom line
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The number of patients having VATS for mesothelioma in these few studies is small. However, most of the studies have concluded that VATS decortication is useful as a palliative measure in advanced malignant mesothelioma. VATS provides a diagnostic tool, yielding tissue for histological diagnosis. Secondly, drainage of effusion and pleurectomy/decortication improves the quality of life and may increase survival as well.
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References
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- Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405–409.[Abstract/Free Full Text]
- Nakas A, Martin Ucar AE, Edwards JG, Waller DA. The role of video assisted thoracoscopic pleurectomy/decortication in the therapeutic management of malignant pleural mesothelioma. Eur J Cardiothorac Surg 2008;33:83–88.[Abstract/Free Full Text]
- Halstead JC, Lim E, Venkateswaran RM, Charman SC, Goddard M, Ritchie AJ. Improved survival with VATS pleurectomy-decortication in advanced malignant mesothelioma. Eur J Surg Oncol 2005;31:314–320.[CrossRef][Medline]
- Martin-Ucar AE, Edwards JG, Rengajaran A, Muller S, Waller DA. Palliative surgical debulking in malignant mesothelioma. Predictors of survival and symptom control. Eur J Cardiothorac Surg 2001;20:1117–1121.[Abstract/Free Full Text]
- Grossebner MW, Arifi AA, Goddard M, Ritchie AJ. Mesothelioma – VATS biopsy and lung mobilization improves diagnosis and palliation. Eur J Cardiothorac Surg 1999;16:619–623.[Abstract/Free Full Text]
- Waller DA, Morritt GN, Forty J. Video-assisted thoracoscopic pleurectomy in the management of malignant pleural effusion. Chest 1995;107:1454–1456.[CrossRef][Medline]
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Abstract
1. Introduction