A Proposed System Toward Standardizing Surgical-Based Treatments for Malignant Pleural Mesothelioma, From the Joint National Cancer Institute-International Association for the Study of Lung Cancer-Mesothelioma Applied Research Foundation Taskforce

Our plain-English summary of A Proposed System Toward Standardizing Surgical-Based Treatments for Malignant Pleural Mesothelioma, From the Joint National Cancer Institute-International Association for the Study of Lung Cancer-Mesothelioma Applied Research Foundation Taskforce, by J.S. Friedberg, M.J. Culligan, A.S. Tsao, et al (Journal of Thoracic Oncology, 2019).

The study

• Authors: J.S. Friedberg, M.J. Culligan, A.S. Tsao, V. Rusch, B. Sepesi, H.I. Pass, R. Bueno, B. Burt, D.J. Sugarbaker, M. de Perrot, A.A. Adjei, P.S. Adusumilli, F.R. Hirsch, S.M. Malik, D.J. Harpole
• Journal: Journal of Thoracic Oncology
• Published: 2019;14(8):1343-1353
• Type of article: Review
• Cited by: 43 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

This article is a joint effort arising from a task force formed at a National Cancer Institute-International Association for the Study of Lung Cancer-Mesothelioma Applied Research Foundation Mesothelioma Clinical Trials Planning Meeting, held at the NIH in March 2017. Malignant pleural mesothelioma remains one of the most virulent and recalcitrant malignancies, still considered incurable, and in desperate need of clinical trials in order to make progress for our patients. Although not standard of care, there is compelling evidence that a select subgroup of mesothelioma patients benefit from a surgery-based multimodal approach. As it is not possible to achieve a microscopically complete resection with mesothelioma, there appears to be no role for surgery alone. Thus, it is anticipated that significant strides in the surgery-based treatment of this cancer will require trials that determine which complementary treatments best augment the cytoreductive efficacy of surgery. Although lung-sacrificing surgery for mesothelioma is fairly standardized, approaches to lung-sparing surgery are highly variable and lung sparing surgery is emerging internationally as the dominant extirpative procedure for this cancer. It is not currently possible to rigorously assess the contribution of the adjuvant treatments combined with surgery because of the variability in procedures used to debulk this cancer, the extreme variability of the cancer itself, the variability in patient selection, the variability in treatment of the inevitable recurrence, and even the variability in follow up schedules. This article is an effort to address these problems by suggesting a more uniform approach to the surgical procedure and also proposing a series of data collection forms that could be adopted immediately, with any eye toward collecting the information that will be necessary to facilitate patient selection and determine which aspects of mesothelioma surgery can and should be standardized - with the goal being extension of life while maintaining quality of life as an equal priority. Furthermore, a completely original contribution in this manuscript is the proposal of a grading system that takes the information from the surgical procedure data forms and generates a completeness of resection score. This is the initial effort to establish a common denominator for mesothelioma surgery that will allow for more accurate comparison between surgical series and better assessment of the impact of the treatments combined with surgery.

Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.

In plain English

This special article was a proposal, not a study. It reported no new patient data. It came out of a March 2017 meeting of the National Cancer Institute, the International Association for the Study of Lung Cancer and the Mesothelioma Applied Research Foundation. The authors stated there is currently no level I evidence supporting surgery for this cancer. They suggested a standard approach to lung-sacrificing surgery (extrapleural pneumonectomy) for malignant pleural mesothelioma and, in more detail, to lung-sparing surgery. They proposed four worksheets: patient selection and staging, details of the lung-sparing operation, a completeness of resection score, and tumor recurrence. The two surgical forms were designed to take no more than 5 to 10 minutes. They recommended a quality-of-life instrument, still being developed by a separate task force, as a fifth worksheet. Suggested follow-up was a history, physical exam and CT scan every 3 months for 2 years, every 4 months in year three, and every 6 months thereafter. The authors concluded this was a first step toward valid comparison between surgical series. They noted that all authors were from North America.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Special article: a consensus proposal from a joint NCI, IASLC and MARF task force for standardizing surgery and data collection in malignant pleural mesothelioma. No patients were studied and no new data were reported.
• Who was studied: No study population. The proposal concerns patients undergoing surgery-based treatment for malignant pleural mesothelioma. It arose from a clinical trials planning meeting in March 2017. The authors were all from North America.
• Exposure: No exposure was studied. Asbestos is mentioned only as the reason, through the latency period, that most patients are older.
• Main results:
  • The authors stated that there is currently no level I evidence supporting surgery as a treatment for malignant pleural mesothelioma.
  • Four data collection worksheets were proposed: patient selection and staging, details of lung-sparing operation, completeness of resection score, and tumor recurrence.
  • The two surgical worksheets, completed by the surgeon right after surgery, were designed to take no more than 5 to 10 minutes.
  • A completeness of resection score was proposed. It is generated from the lung-sparing operation worksheet and is meant to reflect how far macroscopic complete resection (MCR) was achieved.
  • The authors suggested that the definition of macroscopic complete resection include no viable tumor, as well as no visible or palpable tumor.
  • Beyond the standard lung cancer lymph node stations, the authors recommended harvesting phrenic, internal mammary and posterior intercostal lymph nodes.
  • The suggested follow-up after surgery was a history and physical exam plus a CT scan every 3 months for the first 2 years, every 4 months in the third year, and every 6 months thereafter. PET scans and serologic markers were left to the clinician's discretion.
  • A separate task force was still developing a mesothelioma-specific quality-of-life instrument. The authors recommended that it be adopted as a fifth worksheet.
• The authors' conclusion: The authors concluded that the proposal is a first step toward a system allowing valid comparison of results between surgical series and, ultimately, more effective collaborative trials.
• Limitations the authors state:
  • All authors were from North America, so the proposal may not fully match the views of mesothelioma surgeons in Europe or elsewhere.
  • The authors stated that none of the approaches to handling normal-appearing visceral pleura has been proven right or wrong.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Lung Cancer, Mesothelioma, Clinical Trial, Cytoreductive Surgery, Quality of Life.

Related studies

• Current and Future Management of Malignant Mesothelioma: A Consensus Report from the National Cancer Institute Thoracic Malignancy Steering Committee, International Association for the Study of Lung Cancer, and Mesothelioma Applied Research Foundation — A.S. Tsao, O.W. Lindwasser, et al. (2018)
• The Use of Radiation Therapy for the Treatment of Malignant Pleural Mesothelioma: Expert Opinion from the National Cancer Institute Thoracic Malignancy Steering Committee, International Association for the Study of Lung Cancer, and Mesothelioma Applied Research Foundation — D.R. Gomez, A. Rimner, et al. (2019)
• Reply to Waller et al. Standardizing Surgical Treatment for Mesothelioma — J.S. Friedberg, M.J. Culligan, et al. (2020)
• Radiologic Considerations and Standardization of Malignant Pleural Mesothelioma Imaging Within Clinical Trials: Consensus Statement from the NCI Thoracic Malignancy Steering Committee - International Association for the Study of Lung Cancer - Mesothelioma Applied Research Foundation Clinical Trials Planning Meeting — R.R. Gill, A.S. Tsao, et al. (2019)
• Standardizing Surgical Treatment of Malignant Pleural Mesothelioma — D.A. Waller, R. Bilancia, et al. (2020)
• The role of surgical cytoreduction in the treatment of malignant pleural mesothelioma: meeting summary of the International Mesothelioma Interest Group Congress, September 11-14, 2012, Boston, Mass — V. Rusch, E.H. Baldini, et al. (2013)

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