Is less also better? A single-institution experience on treatment of early stage Malignant Pleural Mesothelioma

Our plain-English summary of Is less also better? A single-institution experience on treatment of early stage Malignant Pleural Mesothelioma, by P. Bertoglio, M.C. Ambrogi, A. Chella, et al (European Journal of Surgical Oncology, 2017).

The study

• Authors: P. Bertoglio, M.C. Ambrogi, A. Chella, V. Aprile, P. Dini, S. Korasidis, O. Fanucchi, A. Mussi
• Journal: European Journal of Surgical Oncology
• Published: 2017;43(7):1365-1371
• Cited by: 12 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objectives: No clear evidence of which surgical procedure should be performed for early stage mesothelioma is available to date. We analyzed our 10-year experience in the treatment of early stage mesothelioma with surgery and Hyperthermic IntraTHOracic Chemotherapy.

Methods: We retrospectively analyzed all cases of histologically proven epithelioid or biphasic IMIG stage I and II mesothelioma that we operated between 2005 and 2014. We performed an open pleurectomy and partial decortication of any visible lesion on the visceral pleura in all cases and both diaphragm and pericardium were always spared; Hyperthermic IntraTHOracic Chemotherapy was ran using Cisplatin 80 mg/m2 and Doxorubicin 25 mg/m2 at a target temperature of 42.5 °C for 60 min.

Results: We operated on 26 patients (23 male and 3 female); epithelioid tumor was diagnosed in 23 cases. Twelve patients were in IMIG stage I and 14 in IMIG stage II; median overall survival for all patients, stage I and II were 35.6, 46 and 23 months respectively and disease free survival was 18, 18 and 16 months respectively. Our results for stage I were better than those reported in literature and were similar for stage II. We observe no 30- and 90- mortality and the rate of severe complication (all CTCAE stage 3) were 30%; the median postoperative stay was 7.5 days.

Conclusions: Our lung sparing approach for the treatment of pleural mesothelioma in early stages allows promising long term outcomes with a complete sparing of pulmonary and diaphragmatic function. Larger studies are needed to confirm our good results.

Copyright © 2017 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

In plain English

This retrospective study from Pisa, Italy, reviewed surgery for early-stage malignant pleural mesothelioma. Of 49 patients treated between 2005 and 2014, 26 (23 men, 3 women) had pathological IMIG stage I (12) or stage II (14) disease. Twenty-three had epithelioid tumors and 3 had biphasic tumors. All had an open pleurectomy removing visible tumor while sparing the diaphragm and pericardium; 2 also had a wedge of lung removed for tumor invasion. This was followed by heated chemotherapy (cisplatin and doxorubicin) in the chest, then further chemotherapy. No patient died within 30 or 90 days of surgery. Thirteen had complications, 8 of them grade 3. Median overall survival was 35.6 months overall, 46 months for stage I and 23 months for stage II, a difference that was not statistically significant. Twenty-one patients (81%) had a recurrence. Patients with epithelioid tumors survived significantly longer than those with biphasic tumors. The authors concluded the approach gave promising results but that larger studies are needed. They noted the small number of patients and the retrospective design. The study did not report patients' asbestos exposure.

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 single-institution case series (surgical outcomes study)
• Who was studied: 26 patients with pathological IMIG stage I (12: 4 stage IA, 8 stage IB) or stage II (14) epithelioid (23) or biphasic (3) malignant pleural mesothelioma. They were drawn from 49 patients treated for the disease at the University Hospital of Pisa, Italy, between 2005 and 2014. There were 23 males and 3 females, with a mean age of 65.9 years (range 45-76). Follow-up ran to December 2015.
• Exposure: This study examined a treatment, not asbestos exposure. The treatment was open pleurectomy with partial decortication of visible lesions on the visceral pleura, sparing the diaphragm and pericardium. In 2 patients a wedge resection of the lung was also performed for lung invasion. Surgery was followed by hyperthermic intrathoracic chemotherapy (HITHOC) with cisplatin 80 mg/sqm and doxorubicin 25 mg/sqm at 42.5°C. Afterwards, patients received at least three cycles of adjuvant cisplatin and pemetrexed. The preoperative history asked about possible asbestos exposure, but no exposure data were reported.
• Main results:
  • Whole cohort of 26 patients: median overall survival was 35.6 months. Survival was 84% at 1 year, 59% at 2 years and 11% at 5 years.
  • Whole cohort: median disease-free survival was 18.0 months, and 21 of 26 patients (81%) had a recurrence. Recurrence was local only in 12 cases, distant only in 3 and both local and distant in 4. The site was missing in 2 cases.
  • Median overall survival was 46 months for stage I and 23 months for stage II. The difference was not statistically significant (p=0.177); the authors attributed this probably to the small numbers.
  • Median disease-free survival was 18 months for stage I and 16 months for stage II (p=0.347).
  • In univariate analysis, epithelioid tumors had significantly better survival than biphasic tumors: median overall survival was 46 versus 10 months (p=0.010). Age above 65 years, gender, side and postoperative complications were not significant factors.
  • Complications occurred in 13 of 26 patients (50%): 5 had CTCAE grade 2 and 8 had CTCAE grade 3 complications. The leading complications were anemia (9 patients) and prolonged air leak (4 patients).
  • No patient died within 30 or 90 days of surgery. The median postoperative stay was 7.5 days (range 5-17).
• The authors' conclusion: The authors concluded that this lung- and diaphragm-sparing approach combined with hyperthermic chemotherapy gave promising outcomes in early-stage malignant pleural mesothelioma. They reported no perioperative mortality, a low complication rate and preservation of respiratory function. They added that larger cohorts are needed to confirm these results.
• Limitations the authors state:
  • The retrospective design may have introduced bias in how patient data were collected.
  • Intraoperative data, including possible minimal R2 resection, were difficult and not always possible to assess.
  • The small number of patients may weaken the statistical power of the analysis and its conclusions.
  • Quality of life after surgery could not be evaluated for patients operated before 2013.

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, Mesothelioma, Intrathoracic, Chemotherapy, Epithelioid, Biphasic Mesothelioma, IMIG, Visceral Pleura.

Related studies

• Repeat cytoreductive surgery and heated intraperitoneal chemotherapy may offer survival benefit for intraperitoneal mesothelioma: a single institution experience — J. Wong, A.L. Koch, et al. (2014)
• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin in pediatric patients with peritoneal mesothelioma: a single institution experience and long term follow up — P. Malekzadeh, M. Good, et al. (2021)
• Evolution of locoregional treatment for peritoneal carcinomatosis: single-center experience of 308 procedures of cytoreductive surgery and perioperative intraperitoneal chemotherapy — T.C. Chua, W. Liauw, et al. (2011)
• Phase II study of gemcitabine plus docetaxel as second-line treatment in malignant pleural mesothelioma: a single institution study — I. Tourkantonis, N. Makrilia, et al. (2011)
• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in Asian patients: 100 consecutive patients in a single institution — M.C. Teo, G.H. Tan, et al. (2013)
• Systemic chemotherapy with pemetrexed and cisplatin for malignant peritoneal mesothelioma: a single institution experience — G. Lainakis, F. Zagouri, et al. (2011)

Browse more research in European Journal of Surgical Oncology, or return to medical research.