Analysis of survival of patients with metastatic malignant pleural mesothelioma

Our plain-English summary of Analysis of survival of patients with metastatic malignant pleural mesothelioma, by A. Billè, L. Okiror, L. Harling, et al (Tumori, 2021).

The study

• Authors: A. Billè, L. Okiror, L. Harling, F. Pernazza, A. Muzio, A. Roveta, F. Grosso
• Journal: Tumori
• Published: 2021;107(2):110-118
• Cited by: 8 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Aim: To report the outcomes and prognosis of patients with malignant pleural mesothelioma (MPM) who present with or develop metastases during treatment.

Methods: This is a retrospective observational study of patients diagnosed with MPM over 7 years. Metastases at presentation or during follow-up were recorded. Multivariate Cox regression was used to evaluate the relationship of clinicopathologic variables and overall survival (OS). Logistic regression was used for propensity score matching of patients to assess chemotherapy treatment effect.

Results: There were 367 patients included with a median age of 71 years (range, 29-91). A total of 69 patients (18%) had metastases: 14 at presentation and 55 during follow-up. Patients presenting with metastases had significantly worse median and 2-year OS compared to those developing metastases during follow-up: 13.3 months (95% confidence interval [CI], 2-24.6 months) and 0% versus 20.2 months (95% CI, 16.7-23.3 months) and 33%, respectively (p = 0.029). Female sex, age >70 years, nonepithelioid histology, and not receiving chemotherapy were independent poor prognostic factors. There was no difference in OS of patients with locally advanced (T4) disease compared to metastatic disease (M1): median OS 10.7 months (95% CI, 5.9-15.6) versus 13.3 months (95% CI, 2-24.6) (p = 0.18), respectively. Following propensity matching, sarcomatoid histology (hazard ratio, 7.86 [95% CI, 3.64-16.95]; p < 0.001) and multiple lines of chemotherapy (hazard ratio, 0.38 [95% CI, 0.19-0.84]; p = 0.015) were significant independent prognostic factors for OS.

Conclusions: T4 disease carries a similar OS as metastatic MPM. Female sex, advanced age, nonepithelioid histology, and not receiving chemotherapy were independent poor prognostic factors.

In plain English

This retrospective study reviewed 367 malignant pleural mesothelioma patients at one institution, 2009 to 2016. Of these, 69 had metastases: 14 at diagnosis, 55 later. Median survival was 13.3 months (95% CI, 2 to 24.6) with metastases at diagnosis versus 20.2 (16.7 to 23.3) with later ones (p = 0.029). In stage IV, median survival did not differ significantly between locally advanced (T4) disease, 10.7 months (5.9 to 15.6), and metastatic (M1) disease, 13.3 (2 to 24.6; p = 0.18). By tumor type, median survival was 17.7 months (15.6 to 19.9) epithelioid, 11.6 (9.1 to 14) biphasic and 7.4 (5.2 to 9.5) sarcomatoid. With chemotherapy it was 16.6 months (14.6 to 18.7), without 9.3 (6.9 to 11.6). The authors concluded that T4 and metastatic disease have similar survival, and that female sex, older age, non-epithelioid histology and no chemotherapy independently predicted worse survival. Yet their table gives women versus men a hazard ratio of 0.65 (95% CI, 0.47 to 0.92), which would normally mean lower risk for women, not higher. They noted single-institution data and possible selection bias in chemotherapy comparisons.

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: Retrospective observational study of a consecutive series of patients at a single institution
• Who was studied: 367 patients diagnosed with malignant pleural mesothelioma (MPM) at a single institution (not named in the text) between January 2009 and March 2016; 250 men; 69 had metastatic disease
• Exposure: The study was about survival, not exposure. Documented asbestos exposure was recorded as a patient characteristic: yes for 227, no for 5 and unknown for 135, with no fiber types given. Chemotherapy, mainly pemetrexed with cisplatin or carboplatin, was analyzed as a treatment factor.
• Main results:
  • Of the 367 patients, 69 had metastatic MPM: 14 at presentation (synchronous) and 55 during treatment or follow-up (metachronous)
  • Patients with metastases at presentation had a median survival of 13.3 months (95% CI, 2–24.6) and 2-year survival of 0%. Patients who developed metastases later had a median survival of 20.2 months (95% CI, 16.7–23.3) and 2-year survival of 33% (p = 0.029).
  • There was no significant difference in survival between locally advanced T4 disease (n = 32) and metastatic M1 disease (n = 14). Median survival was 10.7 months (95% CI, 5.9–15.6) for T4 and 13.3 months (95% CI, 2–24.6) for M1 (p = 0.18).
  • In multivariate analysis of the 270 patients with complete data, sex, age over 70, histology, chemotherapy and number of chemotherapy lines were independent prognostic factors for survival
  • Median survival by tumor type was 17.7 months (95% CI, 15.6–19.9) for epithelioid, 11.6 months (95% CI, 9.1–14) for biphasic and 7.4 months (95% CI, 5.2–9.5) for sarcomatoid. The 2-year survival rates were 31.9%, 13.1% and 0% respectively (p = 0.0001).
  • Patients who received chemotherapy had a median survival of 16.6 months (95% CI, 14.6–18.7) and 2-year survival of 27.7%. Patients who did not had a median survival of 9.3 months (95% CI, 6.9–11.6) and 2-year survival of 15.4%.
  • In a propensity-matched group (72 patients who had chemotherapy and 72 who did not), sarcomatoid histology had worse survival than epithelioid (HR 7.86; 95% CI, 3.64–16.95; p less than 0.001). Three lines of chemotherapy was associated with better survival (HR 0.38; 95% CI, 0.19–0.84; p = 0.015).
  • Having metastatic disease was not significantly correlated with sex, smoking history or asbestos exposure (p = 0.68)
• The authors' conclusion: The authors concluded that T4 disease carries survival similar to metastatic MPM. They also concluded that female sex, advanced age, non-epithelioid histology and not receiving chemotherapy were independent poor prognostic factors.
• Limitations the authors state:
  • Patients came from a single institution, so the results may not apply to an international patient population
  • The survival difference with chemotherapy, and with more lines of chemotherapy, may reflect selection bias based on performance status, comorbidities, frailty and response to treatment
  • The number of patients with metastatic disease was relatively small (69)

Topics

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

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Prognosis, Overall Survival, Chemotherapy, confidence interval, Histology, Sarcomatoid, Hazard Ratio.

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• Clinical picture, response to therapy, and survival of women with diffuse malignant peritoneal mesothelioma — G.H. Eltabbakh, M.S. Piver, et al. (1999)
• Hyponatraemia is a predictor of clinical outcome for malignant pleural mesothelioma — R. Berardi, M. Caramanti, et al. (2015)
• Third-space fluid distribution of pemetrexed in non-small cell lung cancer patients — P.H. Honoré, S.J. Joensen, et al. (2014)
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