THORACIC – Original Submission| Volume 33, ISSUE 3, P873-881, September 2021

Outcomes of Conversion to Extrapleural Pneumonectomy From Pleurectomy/Decortication for Malignant Pleural Mesothelioma

Published:February 17, 2021DOI:
      In recent years, there has been a shift from extrapleural pneumonectomy (EPP) toward pleurectomy/decortication (P/D) as the preferred surgical technique. However, we occasionally encounter difficult cases wherein visceral pleurectomy requires conversion to EPP from P/D. We sought to clarify the preoperative risk factors and clinical outcomes associated with conversion to EPP. We compared and analyzed conversion to EPP and P/D between September 2012 and December 2019. Conversion to EPP was decided in case of diffuse tumor invasion to the pulmonary parenchyma or due to failure of decortication. Univariable regression analysis was performed to determine the association of preoperative variables with conversion to EPP. Survival was analyzed by the Kaplan-Meier method and log-rank test. Of the 181 patients who underwent intended P/D, 145 (80.1%) patients underwent P/D and 18 (9.9%) patients underwent conversion to EPP. The sum of 3-level pleural thickness (P < 0.001), maximum of 3-level pleural thickness (P = 0.006), and clinical T stage (P < 0.001) demonstrated association with conversion to EPP. Overall survival and progression-free survival were significantly worse in the conversion to EPP group (median overall survival, 29.2 months vs 57.0 months [P = 0.008]; median progression-free survival, 15.3 months vs 23.2 months [P = 0.005]. Our data show that approximately 1 of every 10 patients with P/D intention converted to EPP. Preoperative pleural thickness and clinical T stage may be risk factors associated with conversion to EPP. The survival rate of conversion to EPP was worse than that of P/D.

      Graphical Abstract



      ARDS (acute respiratory distress syndrome), CT (computed tomography), EPP (extrapleural pneumonectomy), eP/D (extended pleurectomy/decortication), FEV1 (force expiratory volume in 1 second), MCR (macroscopic complete resection), MPM (malignant pleural mesothelioma), NAC (neoadjuvant chemotherapy), P/D (pleurectomy/decortication), PFS (progression-free survival), PS (performance status), OR (odds ratio), OS (overall survival)
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      Linked Article

      • Commentary: To Preserve or Not Preserve (The Lung): That Is the MPM Question
        Seminars in Thoracic and Cardiovascular SurgeryVol. 33Issue 3
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          Dr Nakamura and colleagues report their experience with conversion to extrapleural pneumonectomy (EPP) during planned extended pleurectomy and decortication (ePD) for patients with malignant pleural mesothelioma (MPM).1 They found that the increase in preoperative tumor thickness at three levels (and T stage) was associated with conversion. Both the assessment of prognostic factors and the conversion strategy warrant discussion.
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