Diffuse, mixed malignant pleural mesothelioma

Our plain-English summary of Diffuse, mixed malignant pleural mesothelioma, by R.J. Lewis, G.E. Sisler, J.W. Mackenzie (The Annals of Thoracic Surgery, 1981).

The study

• Authors: R.J. Lewis, G.E. Sisler, J.W. Mackenzie
• Journal: The Annals of Thoracic Surgery
• Published: 1981;31(1):53-60
• Type of article: Case report
• Cited by: 30 articles, as counted by NIH iCite
• Read it: PubMed · Publisher
• In J-M's library: Johns-Manville's company medical library held a copy (J-M no. 001807).

Abstract

Forty-six patients with diffuse, mixed malignant pleural mesothelioma were treated between January, 1970, and May, 1979. All had a history of exposure to asbestos. The diagnosis was established by thoracentesis in 3 patients, thoracoscopy in 28, thoracotomy in 5, and minithoracotomy in 9. Mediastinoscopy was performed in 31 patients and bronchoscopy in 32. Mediastinoscopy was positive in only 1 patient, and in no patient was bronchoscopy positive. Ten patients received no definitive therapy and survived an average of 9.1 months (1 lived for 16 months). Thirty-one patients received chemotherapy and survived an average of 9.6 months, the 2 longest survivors each lived for 24 months. Five patients appeared to have early disease and therefore underwent thoracotomy. In only 2 of these patients did resection of all gross disease appear possible. One patient with incomplete removal is still alive after 9 months. The other 4 are all dead, having survived an average of only 6.75 months. We believe that pleural mesothelioma should be considered an unresectable neoplasm because of its multicentric origin and its diffusely invasive nature, and that attempts at partial or complete resection are not indicated. Until prospective, controlled studies demonstrate otherwise, patients with diffuse, mixed malignant mesothelioma should have the most benign surgical procedure necessary to establish a diagnosis.

In plain English

A surgery department in Piscataway, New Jersey, described 46 consecutive patients with diffuse, mixed malignant pleural mesothelioma treated between January 1970 and May 1979. The patients (37 men, 9 women, aged 38 to 80) were all exposed to crocidolite, amosite and what the article calls 'chrysolite' asbestos fibers. Forty-four worked in an asbestos factory and 2 lived in the surrounding city. Of 32 patients who had bronchoscopy, none tested positive; of 31 who had mediastinoscopy, 1 did. Ten patients who received no radiation or chemotherapy survived an average of 9.1 months. Thirty-one given chemotherapy survived an average of 9.6 months. Five patients whose disease looked early had surgery, and the article reports that four of them died of massive tumor recurrence after an average of 6.75 months. Viewed through the thoracoscope, a clean removal or even substantial debulking was judged not feasible in more than 90% of patients. The authors concluded that pleural mesothelioma should be considered unresectable. Until prospective controlled studies show otherwise, they wrote, patients should have only the least invasive procedure needed for diagnosis.

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: Case series of consecutive patients seen by one surgical group, with six individual case reports
• Who was studied: 46 patients with diffuse, mixed malignant pleural mesothelioma (37 men and 9 women, aged 38 to 80) treated January 1970 to May 1979 at the College of Medicine and Dentistry of New Jersey-Rutgers Medical School, Piscataway, NJ
• Exposure: All patients were exposed to crocidolite, amosite and 'chrysolite' (as printed) asbestos fibers for varying periods. 44 worked in an asbestos factory and 2 lived in the surrounding city. The case reports include a woman who played on an asbestos dump as a child, a woman who as a child washed her factory-worker mother's clothes, and men employed in an asbestos factory for only 4 months and 2 months.
• Main results:
  • Of the 46 patients, 44 worked in an asbestos factory and 2 merely lived in the surrounding city
  • The diagnosis was made by thoracoscopy in 28 patients, minithoracotomy in 9, formal thoracotomy in 5, and thoracentesis (fluid drawn from the chest) in 3
  • Mediastinoscopy was performed in 31 patients and was positive in only 1. Bronchoscopy was performed in 32 patients and was positive in none.
  • Ten patients who received no radiation therapy or chemotherapy after diagnosis survived an average of 9.1 months
  • Thirty-one patients who received chemotherapy survived an average of 9.6 months
  • Among the 5 patients with apparently early disease who underwent attempted resection, four died of massive tumor recurrence after an average of 6.75 months
  • Three patients were admitted in a terminal state and died within 7 to 20 days
  • Pathologists first classed 14 tumors as epithelial, 4 as sarcomatous and 28 as mixed, but on further review considered all 46 to be of a mixed variety
  • As viewed at thoracoscopy, a clean resection or substantial debulking was judged not feasible in more than 90% of patients
  • One case-report patient, a 42-year-old woman who had never worked in an asbestos factory, had played on an asbestos dump as a child
• The authors' conclusion: The authors concluded that pleural mesothelioma should be considered an unresectable tumor because of its multicentric origin and diffusely invasive nature, and that attempts at partial or complete resection are not indicated. Until prospective, controlled studies demonstrate otherwise, they recommended the most benign surgical procedure needed to establish a diagnosis.
• Limitations the authors state:
  • In reply to discussants, the author Lewis suggested that the disease seen in Piscataway might differ from that seen elsewhere, since all their patients had similar exposure
  • The authors framed their recommendation as holding only until prospective, controlled studies show otherwise; their own comparison of treatment groups was not a controlled study

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, Thoracentesis, Thoracoscopy, Thoracotomy, Mediastinoscopy, Bronchoscopy, Chemotherapy, Unresectable.

Related studies

• Keratin protein immunoreactivity of sarcomatoid and mixed types of diffuse malignant mesothelioma: an immunoperoxidase study of 30 cases — A.G. Montag, G.S. Pinkus, et al. (1988)
• Guidelines for the cytopathologic diagnosis of epithelioid and mixed-type malignant mesothelioma: Complementary Statement from the International Mesothelioma Interest Group, Also Endorsed by the International Academy of Cytology and the Papanicolaou Society of Cytopathology — A. Hjerpe, V. Ascoli, et al. (2015)
• Diffuse malignant mesothelioma of pleura. Diagnosis and survival in 92 cases — V.I. Adams, K.K. Unni, et al. (1986)
• Clinicopathologic features and prognostic significance of lung tumours with mixed histologic patterns — E. Cakir, E. Demirag, et al. (2009)
• Exfoliative cytology of diffuse mesothelioma — G.H. Roberts, G.M. Campbell (1972)
• Radiological features of diffuse mesothelioma — A. Solomon (1970)

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