Is There a Role for Cancer-Directed Surgery in Early-Stage Sarcomatoid or Biphasic Mesothelioma?

Our plain-English summary of Is There a Role for Cancer-Directed Surgery in Early-Stage Sarcomatoid or Biphasic Mesothelioma?, by S. Kim, D.A. Bull, L. Garland, et al (The Annals of Thoracic Surgery, 2019).

The study

• Authors: S. Kim, D.A. Bull, L. Garland, Z. Khalpey, B. Stea, S. Yi, C.C. Hsu
• Journal: The Annals of Thoracic Surgery
• Published: 2019;107(1):194-201
• Cited by: 16 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Benefits of surgical resection for early-stage nonepithelioid malignant pleural mesothelioma (MPM) have not been clearly elucidated. This study investigated whether cancer-directed surgery affects overall survival compared with nonsurgical therapies for T1-T2 N0 M0 sarcomatoid or biphasic MPM patients.

Methods: Adult patients with clinical stage I or II MPM were identified in the National Cancer Database from 2004 to 2103. Patients who underwent cancer-directed surgery were matched by propensity score with patients who had received chemotherapy/radiotherapy or no treatments. Overall survival was compared using a Cox proportional hazard regression model.

Results: From National Cancer Database queries, 878 patients with clinical stage I or II MPM with sarcomatoid (n = 524) or biphasic (n = 354) histology were identified. Overall median survival was 5.5 months for patients with sarcomatoid mesothelioma. The cancer-directed surgery improved overall survival compared with no operation (median survival, 7.56 months vs 4.21 months, respectively; p < 0.01). In the biphasic group, median overall survival was 12.2 months. Again, the cancer-directed surgery improved survival compared with no operation (15.8 months vs 9.3 months, p < 0.01). For both histologies, the cancer-directed surgery improved overall survival compared with those who underwent chemotherapy or radiotherapy, or both, without resection (p < 0.05). Perioperative mortality was 6.0% at 30 days and 21.4% at 90 days.

Conclusions: The cancer-directed surgery is associated with improved survival in early-stage MPM patients with nonepithelioid histology compared with those who did not undergo resection or chose medical therapy. Given the high perioperative mortality, a careful patient selection and multidisciplinary evaluation is recommended.

Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

In plain English

This study asked whether surgery aimed at the cancer helped people live longer with early-stage (stage I or II) malignant pleural mesothelioma of the sarcomatoid or biphasic cell types. The authors used the U.S. National Cancer Database for patients diagnosed between 2004 and 2013 and found 878 eligible patients. They matched 114 sarcomatoid and 120 biphasic surgery patients one-to-one with similar patients who had no surgery. Among sarcomatoid patients, median survival was 7.56 months with surgery versus 4.21 months without (p less than 0.01). Among biphasic patients, it was 15.8 versus 9.3 months (p less than 0.01). Surgery patients also lived longer than those given chemotherapy or radiotherapy without surgery. Of the surgery patients, 6.0% died within 30 days and 21.4% within 90 days, and early deaths were more common in the sarcomatoid group. The authors concluded that surgery can be a viable option. They called the survival gain modest and pointed to high early mortality. They also noted that unmeasured differences between groups and unknown timing of surgery could have affected the results. The study did not look at 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 analysis of a national cancer registry database, with propensity score matching (1-to-1) of surgery patients to non-surgery patients
• Who was studied: 878 adults in the U.S. National Cancer Database diagnosed 2004 to 2013 with clinical stage I or II (T1-T2 N0 M0) malignant pleural mesothelioma of sarcomatoid (524) or biphasic (354) histology. The matched groups were 114 surgery patients plus 114 non-surgery patients (sarcomatoid) and 120 surgery patients plus 120 non-surgery patients (biphasic).
• Exposure: The comparison studied was treatment, not asbestos. It set cancer-directed surgery (local excision up to radical surgery) against no resection, and also against chemotherapy and/or radiotherapy without resection. The article does not report asbestos exposure.
• Main results:
  • Matched sarcomatoid patients: median survival was 7.56 months with cancer-directed surgery vs 4.21 months with no resection (p < 0.01). Table 2 gives a hazard ratio of 0.51 (95% CI 0.38 to 0.67).
  • Matched biphasic patients: median survival was 15.8 months with surgery vs 9.3 months with no surgery (p < 0.01). Table 2 gives a hazard ratio of 0.57 (95% CI 0.43 to 0.75).
  • Compared with patients given chemotherapy or radiotherapy (or both) without resection, surgery was associated with longer survival. Sarcomatoid: hazard ratio 0.65 (95% CI 0.46 to 0.92). Biphasic: hazard ratio 0.6 (95% CI 0.44 to 0.83).
  • Among matched surgery patients, 6.0% died within 30 days and 21.4% within 90 days. At 30 days the rate was 9.7% for sarcomatoid and 2.5% for biphasic patients. At 90 days it was 29.8% and 13.3%.
  • Counting only surgery patients who survived to 90 days, median survival rose from 7.56 to 12.2 months (sarcomatoid) and from 15.8 to 17.84 months (biphasic).
  • In the multivariate analysis of all (unmatched) patients, cancer-directed surgery remained associated with longer survival than no resection (hazard ratio 0.66; 95% CI 0.55 to 0.78).
• The authors' conclusion: The authors concluded that cancer-directed surgery can be a viable treatment option for early-stage mesothelioma with biphasic or sarcomatoid histology.
• Limitations the authors state:
  • The authors noted that the survival improvement was modest and that surgery carried high morbidity and early mortality.
  • The database did not record whether surgery was immediate or delayed, which could cause guarantee-time bias.
  • Selection bias was possible. Confounders that were not measured, and so not handled by the propensity matching, could have skewed the results.
  • The database lacks data on tumor recurrence and patterns of recurrence.
  • After matching, biphasic surgery patients more often received radiation than biphasic non-surgery patients.

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: Sarcomatoid, Biphasic Mesothelioma, Surgical Resection, Pleural Mesothelioma, Overall Survival, Chemotherapy, Histology, Median Survival.

Related studies

• Long-term survival after lung-sparing total pleurectomy for locally advanced (International Mesothelioma Interest Group Stage T3-T4) non-sarcomatoid malignant pleural mesothelioma — A. Nakas, E. von Meyenfeldt, et al. (2012)
• Frequency of use and predictors of cancer-directed surgery in the management of malignant pleural mesothelioma in a community-based (Surveillance, Epidemiology, and End Results [SEER]) population — R.M. Flores, E. Riedel, et al. (2010)
• The new case for cervical mediastinoscopy in selection for radical surgery for malignant pleural mesothelioma — A. Nakas, D. Waller, et al. (2012)
• Staging of patients after extrapleural pneumonectomy for malignant pleural mesothelioma--institutional review and current update — C. Cao, S.K. Krog Andvik, et al. (2011)
• The management of the diaphragm during radical surgery for malignant pleural mesothelioma — A.J. Sharkey, R. Bilancia, et al. (2016)
• Second surgery for recurrence of malignant pleural mesothelioma after extrapleural pneumonectomy — L. Politi, G. Borzellino (2010)

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