Malignant pleural mesothelioma: Comparison of surgery-based trimodality therapy to medical therapy at two tertiary academic institutions

Our plain-English summary of Malignant pleural mesothelioma: Comparison of surgery-based trimodality therapy to medical therapy at two tertiary academic institutions, by F. Larose, N. Quigley, Y. Lacasse, et al (Lung Cancer, 2021).

The study

• Authors: F. Larose, N. Quigley, Y. Lacasse, S. Martel, L. Lang-Lazdunski
• Journal: Lung Cancer
• Published: 2021;156:151-156
• Cited by: 12 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objectives: Medical management based on palliative chemotherapy is currently the standard of care in malignant pleural mesothelioma (MPM). Median survival of 12-16 months has been reported with modern chemotherapy regimens with or without anti-angiogenic agents. Multimodality therapy incorporating cytoreductive surgery, systemic chemotherapy and radiotherapy has been offered for years to fit patients with early-stage disease, but its role remains debated. Our objective was to compare overall survival in patients offered multimodality therapy in a specialized clinic setting in London, UK to that of patients offered exclusively medical treatment at another academic institution in Quebec, Canada.

Materials And Methods: We retrospectively compared the survival rates of 2 separate cohorts of patients treated consecutively: Cohort 1 (n = 106) received multimodality therapy including systemic chemotherapy, extended pleurectomy/decortication (P/D) and prophylactic radiotherapy in London (United Kingdom) between 2009 and 2016, while Cohort 2 (n = 98) received medical treatment at the Quebec Heart and Lung Institute (Canada) during the same period.

Results: In Cohort 1, all patients but two completed trimodality therapy. In cohort 2, 51 % received palliative care only and 40 % received systemic chemotherapy. Median survival was 32 months vs 10 months in Cohort 1 and Cohort 2, respectively (hazard ratio with age, gender, pathology and TNM staging as covariates: 3.81; 95 % CI: 2.67-5.45; p < 0.0001). Similar results were obtained in sensitivity analyses, after excluding those who received best supportive care only and in a propensity score-matched analysis.

Conclusion: Aggressive therapy of MPM using cancer-directed surgery, systemic chemotherapy and prophylactic radiotherapy may provide a significant survival benefit in selected patients.

Copyright © 2021 Elsevier B.V. All rights reserved.

In plain English

This retrospective study compared survival in two groups of patients with malignant pleural mesothelioma treated from 2009 to 2016. In London, 106 consecutive patients received trimodality therapy: surgery to remove the pleura (pleurectomy/decortication), chemotherapy before and/or after surgery, and preventive radiotherapy. At the Quebec Heart and Lung Institute in Canada, 98 consecutive patients received medical treatment only. Of these, 51% received palliative care only and 40% received chemotherapy. The study compared treatments and did not analyze asbestos exposure. Median survival was 32 months in the London group and 10 months in the Quebec group. Five-year survival was 23% versus 3%. After adjusting for age, gender, tumor type and stage, the hazard ratio was 3.81 (95% CI 2.67 to 5.45), which the authors reported as indicating better survival in the surgical group. In 58 matched pairs, median survival was 33 versus 9 months. The authors concluded that this aggressive approach might provide a significant survival benefit in selected patients. They noted several limitations: the comparison was not randomized and confounding may favor surgery, performance status was poorly documented, PET-CT staging was lacking in the Canadian group, and the results come from one experienced surgical practice.

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 comparison of two separate cohorts of consecutive patients, one from each of two institutions
• Who was studied: Patients with malignant pleural mesothelioma. Cohort 1 was 106 consecutive patients treated with trimodality therapy in a single academic practice in London, UK, from 2009 to 2016. Cohort 2 was 98 consecutive patients treated only medically at the Quebec Heart and Lung Institute, Quebec City, Canada, over the same period (January 2009 to July 2016).
• Exposure: The study compared two treatments. The first was trimodality therapy: pleurectomy/decortication with hyperthermic pleural lavage with povidone-iodine, induction and/or adjuvant chemotherapy (pemetrexed and cisplatin), and post-operative prophylactic radiotherapy (21 Gy in 3 daily fractions). The second was medical management only: palliative chemotherapy, radiotherapy and/or best supportive care. Asbestos exposure was not analyzed. It was mentioned only as part of the diagnostic basis for two Canadian patients, and no fiber types are reported.
• Main results:
  • In the Canadian cohort (n = 98), 50 (51%) received palliative care only and 39 (40%) received chemotherapy.
  • Median survival was 32 months in the trimodality (London) cohort and 10 months in the medical (Quebec) cohort (log rank p less than 0.0001).
  • Overall survival at 3, 4 and 5 years was 40%, 29% and 23% in the British cohort, versus 6%, 4% and 3% in the Canadian cohort.
  • Adjusted for age, gender, pathology and staging, the hazard ratio comparing the trimodality cohort with the medical therapy cohort was 3.81 (95% CI 2.67 to 5.45; p less than 0.0001). The authors reported that all models indicated increased probability of survival in the surgical cohort.
  • In the propensity score analysis of 58 matched pairs, median survival was 33 months (trimodality) versus 9 months (medical), with a hazard ratio of 3.62 (95% CI 2.56 to 5.11; p less than 0.0001).
  • When only the 39 Canadian patients who received chemotherapy were compared with the surgical cohort, median survival in the surgical cohort (32 months) was 16 months longer (log rank p less than 0.0001).
  • In the trimodality cohort, there were no deaths within 90 days after surgery.
  • The cohorts differed at baseline. The British cohort was younger (mean age 64 vs 71) and had less sarcomatoid histology (2% vs 15%), but more often had stage 3–4 disease (79% vs 56%).
• The authors' conclusion: The authors concluded that aggressive therapy combining pleurectomy/decortication, induction and/or adjuvant platinum-based chemotherapy, and radiotherapy might provide a significant survival benefit in selected patients over a more conservative medical approach. They stated that the results of randomized trials (MARS-2 and EORTC L1205) are awaited to confirm this.
• Limitations the authors state:
  • The comparison was not randomized, and confounding factors may favor the surgical approach.
  • Baseline data did not allow a full review of patients' comorbidities.
  • Performance status was poorly documented.
  • PET-CT staging was lacking in the Canadian cohort, which makes its clinical staging uncertain and may have resulted in down staging.
  • Results come from one institution with significant surgical expertise and may not be generalizable to other institutions.

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, Trimodality Therapy, Palliative Care, Chemotherapy, Median Survival, Multimodal Therapy, Cytoreductive Surgery, Overall Survival.

Related studies

• Letter to the Editor: Comment on 'Malignant pleural mesothelioma: Comparison of surgery-based trimodality therapy to medical therapy at two tertiary academic institutions' — (2021)
• Miliary mesothelioma: a new clinical and radiological presentation in mesothelioma patients with prolonged survival after trimodality therapy — L. Purek, S. Laroumagne, et al. (2011)
• 18F-FDG PET/CT in the management of patients with malignant pleural mesothelioma being considered for multimodality therapy: experience of a tertiary referral center — H.S. Elliott, U. Metser, et al. (2018)
• Integrated positron emission tomography-computed tomography does not accurately stage intrathoracic disease of patients undergoing trimodality therapy for malignant pleural mesothelioma — J. Pilling, J.A. Dartnell, et al. (2010)
• Feasibility and safety of outpatient medical thoracoscopy at a large tertiary medical center: a collaborative medical-surgical initiative — Z.S. DePew, D. Wigle, 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)

Browse more research in Lung Cancer, or return to medical research.