Multimodal management of malignant pleural mesothelioma: where are we today?

Our plain-English summary of Multimodal management of malignant pleural mesothelioma: where are we today?, by P.E. Van Schil, I. Opitz, W. Weder, et al (The European Respiratory Journal, 2014).

The study

• Authors: P.E. Van Schil, I. Opitz, W. Weder, C. De Laet, A. Domen, P. Lauwers, J.M. Hendriks, J.P. Van Meerbeeck
• Journal: The European Respiratory Journal
• Published: 2014;44(3):754-64
• Type of article: Editorial
• Cited by: 34 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

The prognosis of patients with malignant pleural mesothelioma remains poor and although it is clear that multimodal therapy is necessary to improve long-term results, precise treatment schemes have not yet been unequivocally established. Single-modality therapy does not have a major impact on long-term survival and combined-modality therapies are being further evaluated. However, the relative contributions of chemotherapy, radiotherapy and surgery have not been clearly determined at the present time. Moreover, the extent of resection and precise surgical procedure remain a highly debated topic. To better compare and combine results from different institutions and trials, uniform definitions of surgical procedures including extrapleural pneumonectomy and different forms of pleurectomy have recently been introduced. Due to the relatively higher morbidity and mortality of extrapleural pneumonectomy, there is currently a shift towards pleurectomy/decortication when a macroscopic complete resection of all tumour can be obtained by this procedure. In most recent trials, induction chemotherapy was administered to improve surgical resection rates but pathological complete responses are infrequently observed. The role of post-operative radiotherapy has to be further elucidated. Further treatment options that are currently explored include hyperthermic intrapleural chemotherapy, immunotherapy, gene therapy and photodynamic therapy. However, no randomised comparisons are available yet.

©ERS 2014.

In plain English

This article was a narrative review of combined treatment for malignant pleural mesothelioma using chemotherapy, radiotherapy and surgery, with an emphasis on surgery. It reported no new patient data. The figures below come from earlier studies it summarised. The review noted that a causative link with asbestos exposure has been repeatedly documented. In an international database of 3101 cases, median survival was 21, 19, 16 and 12 months for stages I to IV. The authors cautioned that these data were collected retrospectively in surgically treated patients and were subject to selection bias. In the randomised MARS 1 feasibility trial, median survival was 14 months for patients who had extrapleural pneumonectomy (removal of the whole lung on one side with the pleura) and 19 months for those who did not. A non-randomised study reported median survival of 12.8 months after extrapleural pneumonectomy and 23 months after pleurectomy/decortication, which leaves the lung in place. The authors concluded that no definite guidelines could yet be given. They wrote that whether pleurectomy/decortication gives similar or better results remains to be proven by a randomised trial.

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, number 4 in the journal series 'Challenges and Controversies in Thoracic Oncology'; no new patient data
• Who was studied: No study population of its own; the review summarised published databases, trials, systematic reviews and guidelines on treatment of malignant pleural mesothelioma
• Exposure: Asbestos exposure was not studied; the review noted that a causative link with asbestos has been repeatedly documented. The treatments reviewed were chemotherapy, radiotherapy and surgery (extrapleural pneumonectomy, pleurectomy/decortication)
• Main results:
  • From the IASLC international database of 3101 retrospectively collected cases (an earlier study): median survival was 21, 19, 16 and 12 months for stages I, II, III and IV
  • From the MARS 1 randomised feasibility trial (an earlier study): median overall survival was 14 months for patients undergoing extrapleural pneumonectomy and 19 months for those not having it; there were three deaths among the 16 patients who underwent extrapleural pneumonectomy (18.8%)
  • From a prospective but non-randomised study (an earlier study): median survival and 5-year survival were 12.8 months and 9% for extrapleural pneumonectomy, and 23 months and 30.1% for pleurectomy/decortication
  • From the EORTC 08031 phase II trimodal therapy trial (an earlier study): 42 of 57 patients (73.7%) had extrapleural pneumonectomy after induction chemotherapy, and overall median survival was 18.4 months
  • From a 2010 systematic review of 34 studies of extrapleural pneumonectomy: median overall survival ranged from 9.4 to 27.5 months and 5-year survival from 0% to 24%
• The authors' conclusion: The authors concluded that the role of extensive surgery is being redefined, that no definite guidelines can yet be provided, and that whether pleurectomy/decortication yields similar or better results than extrapleural pneumonectomy remains to be proven by a randomised controlled trial
• Limitations the authors state:
  • The authors stated that there are no precise treatment guidelines because large randomised controlled trials are lacking
  • The authors stated that the IASLC database findings were collected retrospectively in surgically treated patients and are subject to selection bias

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, Prognosis, Multimodal Therapy, Chemotherapy, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D), Surgical Resection, Immunotherapy.

Related studies

• Taken Together: Effective Multimodal Approaches for Malignant Pleural Mesothelioma — K.J. Song, R.M. Flores, et al. (2020)
• Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma — S. Hasegawa (2014)
• Multimodal therapy of malignant pleural mesothelioma: is the replacement of radical surgery imminent? — J. Lindenmann, V. Matzi, et al. (2013)
• Current surgical strategies for malignant pleural mesothelioma — T. Takuwa, S. Hasegawa (2016)
• Improved Outcomes with Modern Lung-Sparing Trimodality Therapy in Patients with Malignant Pleural Mesothelioma — F. Shaikh, M.G. Zauderer, et al. (2017)
• British Thoracic Society Guideline for the investigation and management of malignant pleural mesothelioma — I. Woolhouse, L. Bishop, et al. (2018)

Browse more research in The European Respiratory Journal, or return to medical research.