No Survival Benefit of Video-Assisted Thoracoscopic Partial Pleurectomy vs Talc Pleurodesis in Malignant Pleural Mesothelioma


Key Points

  • There was no significant difference in 1-year overall survival with video-assisted thoracoscopic partial pleurectomy (VAT-PP) vs talc pleurodesis, although VAT-PP was associated with greater frequency of resolution of pleural effusion at some time points.
  • VAT-PP was associated with significantly more complications and significantly longer hospital stay.

In light of nonrandomized studies suggesting benefit of video-assisted thoracoscopic partial pleurectomy (VAT-PP) in symptom control and survival, Rintoul et al performed a randomized trial (MesoVATS) of VAT-PP vs talc pleurodesis in malignant pleural mesothelioma. As reported in The Lancet, this UK study showed no survival improvement, more frequent complications, and longer hospital stay with VAT-PP.

Study Details

In this open-label trial, 175 patients aged ≥ 18 years with confirmed mesothelioma with pleural effusion were randomly assigned between October 2003 and January 2012 to undergo VAT-PP (n = 87) or talc pleurodesis (n = 188). The primary endpoint was overall survival at 1 year in the intention to treat population.

The VAT-PP and talc pleurodesis groups were generally balanced for age (mean, 69 years in both), sex (86% male in both), European Organisation for Research and Treatment of Cancer (EORTC) risk group (high for 44% and 53%), percent predicted forced expiratory volume (57% and 59%) and vital capacity (61% and 64%), shuttle walk test (406 and 398 m), tumor type (epithelioid in 84% and 83%), International Mesothelioma Interest Group stage (eg, III in 49% and 43%, IV in 27% and 35%), Eastern Cooperative Oncology Group performance status (0 in 24% and 19%, 1 in 60% and 62%), smoking status (61% and 52% former, 33% and 44% never), asbestos exposure (74% and 76%), and dyspnea (78% in both).

Overall Survival and Pleural Effusion

Overall survival at 1 year was 52% in the VAT-PP group and 57% in the talc pleurodesis group (hazard ratio [HR] = 1.04, P = .81). Overall survival at 6 months was 78% vs 80%. Median overall survival was 13.1 vs 13.5 months. Overall survival at 6 months and 1 year was 66% vs 74% and 37% vs 53% among patients with EORTC high risk and 88% vs 85% and 63% vs 61% among patients with low risk (HR = 1.11, P = .51, for overall survival stratified by risk).

In surviving patients, pleural effusion was reported as resolved in 59% of VAT-PP patients vs 37% of talc pleurodesis patients at 1 month (P = .008), 60% vs 60% at 3 months (P = .97), 77% vs 57% at 6 months (P = .028), and 70% vs 77% at 12 months (P = .49).

Complications and Hospital Stay

Surgical complications were significantly more common with VAT-PP, occurring in 24 (31%) of 78 patients completing VAT-PP vs 10 (14%) of 73 completing talc pleurodesis (P = .019); respiratory complications (24% vs 15%, P = .22) and air-leak beyond 10 days (6% vs 1%, P = .21) were nonsignificantly more common with VAT-PP. Median hospital stay was 7 vs 3 days (P < .0001).

The investigators concluded, “VAT-PP is not recommended to improve overall survival in patients with pleural effusion due to malignant pleural mesothelioma, and talc pleurodesis might be preferable considering the fewer complications and shorter hospital stay associated with this treatment.”

Linda Sharples, PhD, of University of Leeds, is the corresponding author for The Lancet article.

The study was funded by the BUPA Foundation. Robert C. Rintoul, FRCP, has been a member of an advisory board for Lilly UK. John G. Edwards, FRCS, reported honoraria from Lilly UK.

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