Comparison of survival after extrapleural pneumonectomy versus pleurectomy/decortication for malignant pleural mesothelioma in the era of macroscopic complete resection: A meta-analysis

Abstract

<b>Background:</b> Malignant pleural mesothelioma (MPM) is a rare malignancy with a poor prognosis. Pleurectomy/decortication (P/D) and extrapleural pneumonectomy (EPP) have been proposed for the surgical treatment of MPM with the goal of macroscopic complete resection (MCR). <b>Aim:</b> We reviewed the available literature on patients with MPM undergoing either EPP or P/D. <b>Methods:</b> A literature search was performed in three databases from 1980 to 2022. The 30 and 90-days mortality, the median overall survival (OS), the MCR&nbsp;rate, and the 1-, 2-, 3-, 5-year survival were the primary endpoints. The complications were the secondary endpoints. A&nbsp;fixed and a random effect model were used, appropriately. The <i>Q</i> statistic and <i>I²</i> statistic were used to assess the heterogeneity among studies. Sensitivity analysis was performed including only studies incorporating the MCR concept. <b>Results:</b> We included eighteen&nbsp;studies with 4,852 patients (kappa=0.972; 95% CI: 0.917, 1.000). The 30-day mortality was higher in the EPP group (OR:2.79 [95% CI:1.30, 6.01]; p=0.009). The OS was increased in the P/D group (WMD:-4.55 [-6.05, -3.04]; p&lt;0.001). No significant differences were found regarding the 90-day mortality, the MCR rate, and the 1-,2-,3-,5-year survival. These findings were further validated by the sensitivity analysis. The incidence of postoperative&nbsp;atrial fibrillation, hemorrhage, bronchopleural fistula, pulmonary embolism, air leak, and reoperation was higher&nbsp;in the EPP group (<i>p</i>&lt;0.05). <b>Conclusion:</b> P/D is associated with enhanced outcomes and should be preferred with the goal of MCR when technically feasible.