ELCC 2016 News: Elderly Patients with Malignant Pleural Mesothelioma Should Not Be Excluded from Extended Pleurectomy Decortication

Rigorous preoperative assessment advisable for older patients with mesothelioma prior to extended pleurectomy decortication

Although age as an isolated variable did not associate with patient outcome following extended pleurectomy decortication (EPD), elderly patients with nodal involvement and those not receiving adjuvant chemotherapy faired more poorly than similar, younger patients.

Findings were presented by Dr. Annabel Sharkey, Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK at the European Lung Cancer Conference (ELCC), held in Geneva, Switzerland, 13 to 16 April, 2016 showing that age was not prognostic of outcome but other factors, such as the presence of more advanced disease, had a greater negative effect on the outcome of older compared with younger patients.

A more selective approach urged for patients over 70 years when considering EPD

She commented that age should not be a reason for exclusion of the elderly from EPD but recommended a more rigorous preoperative evaluation to determine the presence and extent of nodal disease and a thorough assessment of the patient’s fitness to undergo adjuvant chemotherapy be made prior to surgery, since these factors had a greater negative impact on older than younger patients.

Dr. Sharkey and colleagues reviewed data on all patients undergoing EPD that was prospectively collected form from 1999 to 2015 to compare clinical, pathological, outcome and survival data from patients older than 70 years compared with patients younger than 70 years. EPD was performed in all patients with the intent of achieving macroscopic complete resection.

Of 282 patients in this overall cohort, 79 (28.0%) patients were 70 years or over at the time of EPD but other demographic and pathological characteristics were balanced between the two groups.

Older and younger patients demonstrated similar post procedure length of hospital stay and rates of mortality and overall survival

On multivariate analysis, age did not emerge as a significant prognostic factor of outcome, which was similar between the two groups regarding several parameters. In comparison with younger patients, those older than 70 years had a similar length of hospital stay of median 14 days (range: 2 to 93 days) compared with median 12 days (range:  0 to 70 days), in patients younger than 70 years (p = 0.118).

Mortality rates were also similar between the groups following EPD; no intergroup difference was observed between in-hospital mortality rates of 3.5% in younger patients versus 6.5% of elderly patients (p=0.323), or 90-day mortality of 7.9% versus 10.1% in younger versus older patients, respectively (p = 0.635).

Overall survival of patients <70 or ≥ 70 years of age

Overall survival of patients <70 or ≥ 70 years of age

Similar overall survival (OS) was observed of 13.0 months compared with 10.5 months in younger and older patients, respectively (p = 0.683).

On multivariate analysis, two variables emerged as poor prognostic factors for patients overall: Lack of adjuvant therapy, hazard ratio (HR) 2.088; 95% CI 1.372, 3.176 (p = 0.001) and the presence of pre-operative anaemia, HR 1.976; 95%CI 1.294, 3.017 (p = 0.002).

 

Disease characteristics and lack of post surgical adjuvant chemotherapy more greatly impacted outcome in the elderly

Overall survival of patients with non-epithelioid and node positive tumours <70 or ≥ 70 years of age

Overall survival of patients with non-epithelioid and node positive tumours <70 or ≥ 70 years of age

However, among patients with node positive disease, the elderly experienced significantly decreased survival: Elderly patients with non-epithelioid tumours had survival of 3.8 months compared with 6.6 months in younger patients with non-epithelioid tumours (p=0.024)

A significantly greater proportion of elderly patients required intensive care after EPD; 5.4% of younger patients versus 16.8% of elderly patients needed intensive care (p = 0.004) and nearly double the number of older patients developed atrial fibrillation, which was seen in 14.4% of younger compared with 24.7% of older patients  (p = 0.051).

Fewer patients over 70 years of age were given adjuvant chemotherapy post EPD, suggesting that they were not fit enough; 29.6% of elderly patients received adjuvant chemotherapy compared with 45.7% of younger patients (p = 0.040).

Dr Gaetano Rocco of the Department of Thoracic Surgical and Medical Oncology, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy, who discussed the study findings, elaborated the reasons to perform extended pleurectomy decortication. If a macroscopic complete resection is achievable, extended pleurectomy decortication is preferred over extrapleural pneumonectomy due to reduced morbidity and mortality. However, in patients with minimal symptoms, extended pleurectomy decortication may generate worsening of pulmonary function and quality of life (QoL). In symptomatic patients, extended pleurectomy decortication generates a significant and lasting improvement of QoL whereas pulmonary function is unaffected. Transition from extrapleural pneumonectomy to extended pleurectomy decortication may enable surgeons to offer a surgical option to more patients with performance status 1 and it is characterised by a better survival in the elderly (older than 65 years) compared to younger cohorts.

He said that the concept of elderly is different from other publications and questioned choosing a different age cut-off. He asked about selection of the patients for surgery, in particular if an institutional algorithm vs score was in place. He asked if the authors looked at performing a propensity score analysis. What routine risk assessment model did they adopt? He further asked if CPET is standard for preoperative evaluation of these elderly patients and what is the impact of patient’s preference in surgical decision-making. He asked how many of these procedures have been done by VATS. In transition from extrapleural pneumonectomy to extended pleurectomy decortication, the authors have noticed an increasing late reoperation rate for extended pleurectomy decortication. Dr Rocco asked if it applies to the elderly category and how does this affect the subjective and objective outcomes.

Conclusions

The authors underscored that the consideration to offer EPD to older patients with malignant mesothelioma should not be based on age, per se, but upon a determination of the extent of the disease and upon the overall fitness of the patient to undergo adjuvant chemotherapy or neoadjuvant therapy.

Reference

207O. Extended pleurectomy decortication for malignant pleural mesothelioma in the elderly - the need for an inclusive yet selective approach