Local and systemic therapies for malignant pleural mesothelioma

Our plain-English summary of Local and systemic therapies for malignant pleural mesothelioma, by D. Gomez, A.S. Tsao (Current Treatment Options in Oncology, 2014).

The study

• Authors: D. Gomez, A.S. Tsao
• Journal: Current Treatment Options in Oncology
• Published: 2014;15(4):683-99
• Type of article: Review
• Cited by: 15 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Malignant pleural mesothelioma (MPM) is a challenging disease to treat with median overall survival times ranging between 9-17 months for all stages of disease. Recent clinical trials have improved our understanding of the biology of MPM. However, survival results are still not ideal. For early-stage MPM, patients should be evaluated for trimodality therapy in an experienced cancer center. If treating off-protocol, MPM patients should receive a surgical staging evaluation. The decision to proceed with surgical resection also should be considered after an extensive and thorough pulmonary and cardiac evaluation. If deemed a good surgical candidate, patients should receive surgical resection (pleurectomy/decortication or extrapleural pneumonectomy), adjuvant radiation therapy (hemithoracic external beam or intensity modulated radiation therapy), and either neoadjuvant or adjuvant chemotherapy (cisplatin-pemetrexed for 4 cycles). The optimal precise sequence of the trimodality is unclear and should be decided upon by a multidisciplinary consensus for each individual patient. In general, clinical trial participation should be encouraged. Several trials are currently underway to examine intraoperative therapies, vaccines, immunotherapy additions, and novel radiation therapy techniques. Advances in the field of MPM are reliant on participation in clinical trials and identifying biomarkers that are predictive for response to systemic therapies and prognostic for survival benefit.

In plain English

This article was a review, not a new study. The authors, from The University of Texas M. D. Anderson Cancer Center, summarized published and ongoing research on treating malignant pleural mesothelioma, mainly disease that can be removed by surgery. It covered two operations (pleurectomy/decortication and extrapleural pneumonectomy), chemotherapy given before or after surgery, treatments placed directly into the pleural space, and radiation, including intensity modulated radiation therapy (IMRT) and proton therapy. The article did not examine asbestos exposure. Among the studies it described, the MARS trial randomized 50 patients and reported worse survival with extrapleural pneumonectomy (hazard ratio 1.90, 95% confidence interval 0.92 to 3.93, p=0.082). In a Dana-Farber/Brigham and Women's study of IMRT after extrapleural pneumonectomy, 6 of 13 patients died of pneumonitis. The authors noted that trials have been small because the disease is rare, and that the best surgical method remains unknown. They concluded that patients with resectable disease should be encouraged to join clinical trials at experienced centers with dedicated mesothelioma programs.

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: Narrative review of treatment studies (published articles and conference reports) for malignant pleural mesothelioma
• Who was studied: Patients with malignant pleural mesothelioma, mainly earlier-stage or resectable disease, as studied in the trials and reports the review cites
• Exposure: Not reported. The review concerned treatments (surgery, chemotherapy, intrapleural therapies, radiation), not asbestos or other exposures.
• Main results:
  • The review reported that the MARS trial randomized 50 patients to extrapleural pneumonectomy (n=24) or no extrapleural pneumonectomy (n=26). Survival was worse with extrapleural pneumonectomy (HR 1.90, 95% CI 0.92 to 3.93, p=0.082). Median overall survival was 14.4 months in the extrapleural pneumonectomy arm and 19.5 months in the other arm.
  • The review reported that in the MesoVATS trial, overall survival did not differ significantly between video-assisted thoracoscopic partial pleurectomy and talc pleurodesis (HR 1.11, p=0.51).
  • The review reported that in a nonrandomized study by Lang-Lazdunski et al., median overall survival was 23 months in the pleurectomy/decortication arm (54 patients) and 12.8 months in the extrapleural pneumonectomy arm (25 patients).
  • The review reported that in the largest neoadjuvant extrapleural pneumonectomy trial (75 patients given cisplatin-pemetrexed), the response rate was 29%, median time to progression was 13.1 months, and overall survival was 16.6 months.
  • The review reported the authors' institution's earlier published update of 136 patients who had surgical resection with planned IMRT. Two-year locoregional recurrence-free survival was 71% and two-year overall survival was 32%.
  • The review reported that in a Dana-Farber Cancer Institute/Brigham and Women's Hospital study, 6 of 13 patients (46%) treated with extrapleural pneumonectomy and adjuvant IMRT died of fatal pneumonitis.
  • The review reported an M. D. Anderson report comparing 22 patients given IMRT after pleurectomy/decortication with 22 matched patients given IMRT after extrapleural pneumonectomy. Median overall survival was 28.4 vs. 14.2 months (p=0.14), described as a trend.
• The authors' conclusion: The authors concluded that better-designed clinical studies are needed and that patients with resectable malignant pleural mesothelioma should be encouraged to take part in clinical trials at experienced centers with dedicated mesothelioma multimodality programs.
• Limitations the authors state:
  • The authors noted that because the disease is rare, clinical trials in the local-regional setting are limited, with small numbers of eligible patients.
  • The authors stated that the optimal surgical debulking method remains unknown.

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, Median Overall Survival, Clinical Trial, Trimodality Therapy, Staging, Surgical Resection, Pleurectomy/Decortication (P/D), Extrapleural Pneumonectomy (EPP).

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Browse more research in Current Treatment Options in Oncology, or return to medical research.