Faccioli Eleonora, Dell'Amore Andrea, Lorenzoni Giulia, Schiavon Marco, Canu Gianluca, Pasello Giulia, Zambello Giovanni, Sepulcri Matteo, Sambataro Viola, Labella Francesco, Giraudo Chiara, Gregori Dario, Calabrese Fiorella, Rea Federico
Thoracic Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy.
Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy.
Eur J Cardiothorac Surg. 2024 Nov 28;66(6). doi: 10.1093/ejcts/ezae431.
Pleural mesothelioma (PM) is an aggressive disease linked to asbestos exposure, presenting significant treatment challenges. The recommended approach is multimodal treatment, even if the concept of resectable PM and the superiority of one surgical technique over the other [(extended) pleurectomy decortication [(E)PD] vs extra-pleural pneumonectomy (EPP)] are matter of debates. The aim of this study is to compare the 2 techniques in terms of short- and long-term outcomes at a high-volume centre.
Clinical data from PM patients who underwent radical surgery [(E)PD and EPP] between 1994 and 2022 were collected. A propensity score weighting approach was used for non-random intervention allocation. Survival distribution was estimated using Kaplan-Meier method and the association with outcomes was evaluated using a weighted Cox proportional hazard models.
Among 254 patients, 125 (49%) underwent EPP and 129 (51%) (E)PD. The 90-day mortality was higher in the EPP group (7.2% vs 0%; P = 0.01). No difference in 1-, 3- and 5-year survival was found: 65.8%, 26%, 17% for EPP and 75.5%, 39.7% and 21.3% for (E)PD; P = 0.39. The multivariable-weighted Cox model identified no increased risk of death [hazard ratio (HR) 1.25; P = 0.49] or recurrence (HR 1.05; P = 0.858) in the EPP group. Pre-operative total lung capacity was significantly associated with a reduced risk of death (HR 0.96; P = 0.023) and recurrence (HR 0.97; P = 0.019) at follow-up, while pre-operative disease burden to a higher risk of recurrence (HR 1.01; P = 0.02).
Our experience showed acceptable short- and long-term outcomes in both procedures, making EPP still an option only for carefully selected patients at high-volume centre. Surgery, although recently debated, should be performed exclusively in expert centres to minimize post-operative risks. The identification of new prognostic factors is crucial for better selecting patients who may benefit from surgery within the context of multimodal treatment.
胸膜间皮瘤（PM）是一种与石棉暴露相关的侵袭性疾病，带来了重大的治疗挑战。推荐的方法是多模式治疗，即便可切除性PM的概念以及一种手术技术相对于另一种手术技术的优越性[（扩大）胸膜剥脱术[（E）PD]与胸膜外全肺切除术（EPP）]仍存在争议。本研究的目的是在一个大型中心比较这两种技术的短期和长期疗效。
收集了1994年至2022年间接受根治性手术[（E）PD和EPP]的PM患者的临床数据。采用倾向得分加权法进行非随机干预分配。使用Kaplan-Meier方法估计生存分布，并使用加权Cox比例风险模型评估与结局的关联。
254例患者中，125例（49%）接受了EPP，129例（51%）接受了（E）PD。EPP组的90天死亡率更高（7.2%对0%；P = 0.01）。1年、3年和5年生存率未发现差异：EPP组分别为65.8%、26%、17%，（E）PD组分别为75.5%、39.7%和21.3%；P = 0.39。多变量加权Cox模型未发现EPP组死亡风险增加[风险比（HR）1.25；P = 0.49]或复发风险增加（HR 1.05；P = 0.858）。术前肺总量与随访时死亡风险降低（HR 0.96；P = 0.023）和复发风险降低（HR 0.97；P = 0.019）显著相关，而术前疾病负担与复发风险较高相关（HR 1.01；P = 0.02）。
我们的经验表明，两种手术的短期和长期疗效均可接受，这使得EPP仍然只是大型中心精心挑选患者的一种选择。手术虽然最近存在争议，但应仅在专家中心进行，以尽量降低术后风险。识别新的预后因素对于在多模式治疗背景下更好地选择可能从手术中获益的患者至关重要。
