Background. Malignant pleural mesothelioma is a rare thoracic tumour, commonly associated with a history of chronic asbestos exposure, with a highly unfavourable prognosis. To date, the recommended treatment is multimodal, based on a combination of neo-adjuvant chemotherapy, surgery and adjuvant treatment (usually radiotherapy, and more recently immunotherapy in clinical trials). The aim of this study was to analyse short- and long-term outcomes in a large cohort of patients undergoing multimodal treatment in a high-volume centre with high disease expertise. Materials and methods. This is a retrospective monocentric study that considered the data of patients suffering from malignant pleural mesothelioma undergoing surgery in the context of multimodal treatment at the U.O.C. of Thoracic Surgery of the University Hospital of Padua between July 1994 and January 2024 for a total of 351 patients. Continuous variables were analyzed as median and interquartile range while categorical variables as absolute number and frequency. Overall survival was assessed by the Kaplan-Meyer estimator and recurrence by the cumulative incidence function. Univariate analyses for survival, recurrence and post-operative complications were performed, with results reported as hazard ratio, 95% confidence interval and p-value. Results. The sample analysed consisted of 85 (24%) females and 266 (76%) males. The median age of the population is 64 years (IQR 59.70). Regarding the interventions performed, EPD was performed in 124 (35%) cases while in 131 (37%) cases EPP was the intervention of choice. Induction chemotherapy was given in 324 (93%) patients while adjuvant treatment was given in 282 (80%) patients. Peri-operative death occurred in 4 cases (1%). The univariate analysis for complications showed that exploratory thoracotomy surgery is associated with a significantly lower risk than other surgical procedures of complication onset whereas an advanced clinical stage (II and III) is associated with a higher risk of occurrence of post-operative complications. The univariate survival analysis showed that P/D, epithelioid histology and total lung capacity (TLC) are associated with a lower risk of mortality at follow-up. Whereas, partial pleurectomy, exploratory thoracotomy, presence of intra-operative complications, advanced (II and III) TNM stage, both clinical and pathological, and higher disease burden were associated with a higher risk of death at follow-up. The univariate analysis for recurrence showed that EPP, epithelioid histology and total lung capacity (TLC) are significantly associated with a lower risk of developing recurrence in the postoperative period. In contrast, advanced age, presence of other comorbidities, advanced TNM stage (II and III) and high disease burden are significantly associated with a higher risk of recurrence in the postoperative period. Overall survival at 1, 3 and 5 years was 68%, 28% and 17% respectively. The cumulative incidence of recurrence at 1, 3 and 5 years which was 47%, 81% and 85% respectively. Conclusion. The results of the study show that radical surgery represents a valid option in multimodal treatment, especially in centres with high expertise. Although the role of surgery in this area continues to be debated, the identification of prognostic factors and the collection of evidence from high-volume centres remains essential for a better selection of patients eligible for surgical treatment.
Background. Il mesotelioma pleurico maligno è un tumore toracico raro, comunemente associato ad una storia di esposizione cronica all’asbesto, con prognosi altamente infausta. Il trattamento ad oggi raccomandato è quello multimodale, basato su combinazione di chemioterapia neo-adiuvante, chirurgia e trattamento adiuvante (generalmente radioterapico, ed in tempi più recenti immunoterapico nell’ambito di trials clinici). L’obiettivo di questo studio è stata l’analisi degli outcomes a breve e lungo termine in un’ampia coorte di pazienti sottoposti a trattamento multimodale in un centro ad alto volume con elevato expertise della patologia. Materiali e metodi. Si tratta di uno studio retrospettivo monocentrico che ha considerato i dati di pazienti affetti da mesotelioma pleurico maligno sottoposti a chirurgia nell’ambito di trattamento multimodale presso l’U.O.C. di Chirurgia Toracica dell’Azienda ospedaliera universitaria di Padova tra il luglio 1994 e il gennaio 2024 per un totale di 351 pazienti. Le variabili continue sono state analizzate come mediana e range interquartile mentre le variabili categoriche come numero assoluto e frequenza. L’overall-survival è stata valutata mediante lo stimatore di Kaplan-Meyer mentre la recidiva mediante la funzione di incidenza cumulativa. Sono state eseguite analisi univariate per sopravvivenza, recidiva e complicanze post-operatorie riportando i risultati come hazard ratio, intervallo di confidenza al 95% e p-value. Risultati. Il campione analizzato è risultato composto da 85 (24%) femmine e 266 (76%) maschi. L’età mediana della popolazione è 64 anni (IQR 59,70). Per quanto concerne gli interventi eseguiti, in 124 (35%) casi è stato effettuato un intervento di EPD mentre in 131 (37%) casi l’intervento scelto è stato l’EPP. La chemioterapia di induzione è stata effettuata in 324 (93%) pazienti mentre il trattamento adiuvante ha riguardato 282 (80%) pazienti. In 4 casi (1%) si è assistito a morte peri-operatoria. L’analisi univariata per complicanze ha mostrato che l’intervento di toracotomia esplorativa è associato ad un rischio significativamente minore rispetto alle altre procedure chirurgiche di insorgenza di complicanze mentre lo stadio clinico avanzato (II e III) è associato ad un rischio più elevato di comparsa delle stesse. L’analisi univariata per sopravvivenza ha evidenziato come l’intervento di PD, l’istologia epitelioide e la capacità polmonare totale (TLC) siano associati ad un minore rischio di mortalità al follow-up. Invece, la pleurectomia parziale, la toracotomia esplorativa, la comparsa di complicanze intra-operatorie, lo stadio TNM, sia clinico che patologico, avanzato (II e III) ed un disease burden più elevato sono risultati associati ad un rischio più elevato di morte al follow up. L’analisi univariata per recidiva ha mostrato che l’intervento di EPP, l’istologia epitelioide e la capacità polmonare totale (TLC) sono significativamente associate ad un rischio minore di sviluppo di recidiva nel post-operatorio. Al contrario, l’età avanzata la presenza di altre comorbidità, uno stadio TNM avanzato (II e III) e un disease burden elevato sono significativamente associati ad un rischio più elevato di recidiva nel post-operatorio. L’overall survival dei pazienti a 1, 3 e 5 anni è risultata rispettivamente del 68%, 28% e 17% . L’incidenza cumulativa di recidiva a 1, 3 e 5 anni che è risultata rispettivamente del 47%, 81% e 85%. Conclusione. I risultati dello studio mostrano come la chirurgia ad intento radicale rappresenti una valida opzione nell’ambito del trattamento multimodale, in particolare in centri ad elevato expertise. Nonostante il ruolo della chirurgia in questo ambito continui ad essere dibattuto, l’identificazione di fattori prognostici e la raccolta di evidenze da centri ad alto volume rimane essenziale per una migliore selezione dei pazienti candidabili a trattamento chirurgico.
La chirurgia del mesotelioma pleurico nell'ambito del trattamento multimodale: risultati a breve e lungo termine del nostro centro
MATTIUZZI, MARTINA
2023/2024
Abstract
Background. Malignant pleural mesothelioma is a rare thoracic tumour, commonly associated with a history of chronic asbestos exposure, with a highly unfavourable prognosis. To date, the recommended treatment is multimodal, based on a combination of neo-adjuvant chemotherapy, surgery and adjuvant treatment (usually radiotherapy, and more recently immunotherapy in clinical trials). The aim of this study was to analyse short- and long-term outcomes in a large cohort of patients undergoing multimodal treatment in a high-volume centre with high disease expertise. Materials and methods. This is a retrospective monocentric study that considered the data of patients suffering from malignant pleural mesothelioma undergoing surgery in the context of multimodal treatment at the U.O.C. of Thoracic Surgery of the University Hospital of Padua between July 1994 and January 2024 for a total of 351 patients. Continuous variables were analyzed as median and interquartile range while categorical variables as absolute number and frequency. Overall survival was assessed by the Kaplan-Meyer estimator and recurrence by the cumulative incidence function. Univariate analyses for survival, recurrence and post-operative complications were performed, with results reported as hazard ratio, 95% confidence interval and p-value. Results. The sample analysed consisted of 85 (24%) females and 266 (76%) males. The median age of the population is 64 years (IQR 59.70). Regarding the interventions performed, EPD was performed in 124 (35%) cases while in 131 (37%) cases EPP was the intervention of choice. Induction chemotherapy was given in 324 (93%) patients while adjuvant treatment was given in 282 (80%) patients. Peri-operative death occurred in 4 cases (1%). The univariate analysis for complications showed that exploratory thoracotomy surgery is associated with a significantly lower risk than other surgical procedures of complication onset whereas an advanced clinical stage (II and III) is associated with a higher risk of occurrence of post-operative complications. The univariate survival analysis showed that P/D, epithelioid histology and total lung capacity (TLC) are associated with a lower risk of mortality at follow-up. Whereas, partial pleurectomy, exploratory thoracotomy, presence of intra-operative complications, advanced (II and III) TNM stage, both clinical and pathological, and higher disease burden were associated with a higher risk of death at follow-up. The univariate analysis for recurrence showed that EPP, epithelioid histology and total lung capacity (TLC) are significantly associated with a lower risk of developing recurrence in the postoperative period. In contrast, advanced age, presence of other comorbidities, advanced TNM stage (II and III) and high disease burden are significantly associated with a higher risk of recurrence in the postoperative period. Overall survival at 1, 3 and 5 years was 68%, 28% and 17% respectively. The cumulative incidence of recurrence at 1, 3 and 5 years which was 47%, 81% and 85% respectively. Conclusion. The results of the study show that radical surgery represents a valid option in multimodal treatment, especially in centres with high expertise. Although the role of surgery in this area continues to be debated, the identification of prognostic factors and the collection of evidence from high-volume centres remains essential for a better selection of patients eligible for surgical treatment.| File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.12608/72923