Surgery for pleural mesothelioma in multimodality setting: comparison between surgical techniques in a high-volume centre

Objectives: 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.

Methods: 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.

Results: 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).

Conclusions: 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.