Multimodal therapy of malignant pleural mesothelioma: is the replacement of radical surgery imminent?

Our plain-English summary of Multimodal therapy of malignant pleural mesothelioma: is the replacement of radical surgery imminent?, by J. Lindenmann, V. Matzi, N. Neuboeck, et al (Interactive Cardiovascular and Thoracic Surgery, 2013).

The study

• Authors: J. Lindenmann, V. Matzi, N. Neuboeck, U. Anegg, A. Maier, J. Smolle, F.M. Smolle-Juettner
• Journal: Interactive Cardiovascular and Thoracic Surgery
• Published: 2013;16(3):237-43
• Cited by: 13 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Objectives: Malignant pleural mesothelioma (MPM) remains an aggressive thoracic malignancy associated with poor prognosis. There is no standard treatment regimen, and particularly, the impact of radical surgery remains controversial. The main goal of our retrospective single-centre study was to evaluate the surgical and non-surgical treatment modalities applied at our division regarding their effect on the patient's survival.

Methods: During the last decade, 82 patients with histologically confirmed MPM were treated at our division. The complete clinical records of 61 patients were eligible for statistical evaluation.

Results: There were 14 women (23%) and 47 men (77%) with a mean age of 63.7 years. Epitheloid subtype was found in 48 patients (78.7%), sarcomatoid in 3 (4.9%) and biphasic in 10 (16%). Surgery as the first treatment modality was performed in 44 patients (72.1%). Pleurectomy/decortication was done in 28 cases (45.9%), extended pleurectomy/decortication was performed in 13 (21.3%) and extrapleural pneumonectomy in 3 (4.9%). Additional intraoperative photodynamic therapy was administered in 20 patients, 34 underwent chemotherapy (55.7%) and 12 had radiotherapy (19.7%). Mean survival time for the collective was 18.3 months. Five-year survival was 17% in the epitheloid histology group, where patients treated with chemotherapy alone yielded a significant increase in survival (P = 0.049), and those with other subtypes survived for a maximum of 20.6 months.

Conclusions: Chemotherapy and pleurectomy/decortication can extend the survival time of patients with MPM remarkably. The adequate treatment options have to be tailored to the specific particular needs of each patient considering histological subtype, tumour stage and patient's individual functional assessment as well as comorbidity.

In plain English

This retrospective single-centre study, from the Medical University of Graz, Austria, reviewed records of 61 patients with malignant mesothelioma treated between January 2000 and December 2009. Most had pleural disease; one had peritoneal mesothelioma and two had both. Patients often received several treatments, including pleurectomy/decortication (P/D), extrapleural pneumonectomy (EPP, 3 patients), photodynamic therapy during surgery, chemotherapy, radiotherapy and pleurodesis; the authors examined survival for several of these. A history of asbestos exposure was reported in 25 patients (41.7%) and did not significantly influence survival. Mean overall survival was 22.3 months (median 15.4). Patients with the epitheloid subtype survived longer than those with other subtypes (P = 0.029), and non-smokers longer than smokers (median 19.6 vs 10.1 months). Among epitheloid patients, P/D was linked to longer survival, but not statistically significantly (P = 0.055). Epitheloid patients given chemotherapy without P/D survived longer than those without chemotherapy (P = 0.049). The authors concluded that only epitheloid patients at IMIG stage I or II should have lung-sparing surgery within multimodal treatment. They cautioned that their sample was small and varied.

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-centre study of patient records (treatment outcomes)
• Who was studied: 61 patients with malignant mesothelioma (14 women, 47 men; mean age 63.7) referred to the Division of Thoracic and Hyperbaric Surgery, Medical University of Graz, Austria, between January 2000 and December 2009, with observation ending in 2011. The abstract states that 82 patients were treated, of whom 61 had complete records.
• Exposure: The study examined treatments, not asbestos exposure. A history of asbestos exposure was recorded in 25 patients (41.7%). No fiber types or doses are given.
• Main results:
  • Disease site: mesothelioma of the pleura in 59 patients (96.7%), of the peritoneum only in 1, and of both pleura and peritoneum in 2.
  • In most cases, patients received several treatments each.
  • All 61 patients: mean overall survival was 22.3 months (median 15.4 months).
  • Epitheloid subtype group: five-year survival was 17% (mean 25.9, median 18.3 months). Patients with other subtypes survived at most 20.6 months (mean 10.1, median 10.8). The difference was statistically significant, P = 0.029.
  • Patients with tumour grade G1 had significantly higher median survival than those with G2 or G3 (P = 0.019).
  • Non-smokers had significantly higher median survival than smokers: 19.6 vs 10.1 months, P less than 0.0001.
  • Neither a history of asbestos exposure nor any comorbidity had a significant influence on survival.
  • Among the 48 epitheloid patients, women survived significantly longer than men (median 23.3 vs 15.3 months, P = 0.029). In all patients, the difference between women and men was not significant (P = 0.06).
  • Epitheloid patients treated with P/D survived longer than those treated otherwise (mean 30.4 vs 14.2 months; median 19.8 vs 14.7 months). The difference was not statistically significant (P = 0.055).
  • Epitheloid patients given chemotherapy without P/D had a mean survival of 19.1 months (median 23.3), compared with a mean of 10.4 months (median 10.7) for those without chemotherapy. P = 0.049, statistically significant. Chemotherapy showed no significant benefit in other subtypes.
  • Among the 41 patients who had P/D, adding chemotherapy, radiotherapy or intraoperative photodynamic therapy had no statistically significant impact on survival. No surgical procedure significantly influenced survival.
  • Among surgical patients, 10 (16.4%) needed repeat surgery, and there were no deaths within 30 days.
• The authors' conclusion: The authors concluded that only patients with epitheloid mesothelioma and IMIG stage I or II should undergo lung-sparing surgery within multimodal treatment. They also wrote that multimodal treatment may improve median survival.
• Limitations the authors state:
  • The authors said conclusions should be drawn very carefully because the sample was relatively small and the patients were heterogeneous.
  • The EPP group had only 3 patients, too few for a serious comparison. The authors' view that EPP should be avoided rests mainly on other published studies.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Multimodal Therapy, Pleural Mesothelioma, Prognosis, Sarcomatoid, Biphasic Mesothelioma, Pleurectomy/Decortication (P/D), Extrapleural Pneumonectomy (EPP), Chemotherapy.

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