Multimodal Treatment of Malignant Pleural Mesothelioma: Real-World Experience with 112 Patients

Our plain-English summary of Multimodal Treatment of Malignant Pleural Mesothelioma: Real-World Experience with 112 Patients, by A. Holzknecht, O. Illini, M.J. Hochmair, et al (Cancers, 2022).

The study

• Authors: A. Holzknecht, O. Illini, M.J. Hochmair, D. Krenbek, U. Setinek, F. Huemer, E. Bitterlich, C. Kaindl, V. Getman, A. Akan, M. Weber, G. Leobacher, A. Valipour, M.R. Mueller, S.B. Watzka
• Journal: Cancers
• Published: 2022;14(9)
• Cited by: 7 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant pleural mesothelioma (MPM) is a rare pleural cancer associated with asbestos exposure. According to current evidence, the combination of chemotherapy, surgery and radiotherapy improves patients’ survival. However, the optimal sequence and weighting of the respective treatment modalities is unclear. In anticipation of the upcoming results of the MARS-2 trial, we sought to determine the relative impact of the respective treatment modalities on complications and overall survival in our own consecutive institutional series of 112 patients. Fifty-seven patients (51%) underwent multimodality therapy with curative intent, while 55 patients (49%) were treated with palliative intent. The median overall survival (OS) of the entire cohort was 16.9 months (95% CI: 13.4−20.4) after diagnosis; 5-year survival was 29% for patients who underwent lung-preserving surgery. In univariate analysis, surgical treatment (p < 0.001), multimodality therapy (p < 0.001), epithelioid subtype (p < 0.001), early tumor stage (p = 0.02) and the absence of arterial hypertension (p = 0.034) were found to be prognostic factors for OS. In multivariate analysis, epithelioid subtype was associated with a survival benefit, whereas the occurrence of complications was associated with worse OS. Multimodality therapy including surgery significantly prolonged the OS of MPM patients compared with multimodal therapy without surgery.

In plain English

This retrospective study reviewed records of 112 consecutive patients with malignant pleural mesothelioma treated at a referral center in Vienna, Austria, from January 2000 to May 2020. Asbestos exposure was not reported. Forty patients had lung-preserving surgery and nine had extrapleural pneumonectomy, which removes the whole lung. Median overall survival from diagnosis was 16.9 months (95% CI 13.4 to 20.4) overall. It was 20.3 months (16.9 to 23.7) for epithelioid subtype versus 6.8 months (3.2 to 10.4) for other subtypes. It was 25.5 months (15.1 to 35.9) after lung-preserving surgery and 12.3 months (12.1 to 13.5) after extrapleural pneumonectomy, though a table prints other intervals. Of 49 patients operated on with curative intent, 29 (59.2%) had complications; none died within 30 days. In the adjusted analysis, epithelioid subtype and earlier stage were linked to better survival, and arterial hypertension and cardiac decompensation to worse. Surgery was not identified as a statistically significant independent factor. The authors noted its apparent benefit might reflect selection of fitter patients. They concluded that strictly following a standardized treatment algorithm might help define accepted standards.

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-center review of medical records (consecutive case series)
• Who was studied: 112 consecutive patients with malignant pleural mesothelioma treated at a referral center for thoracic oncology and thoracic surgery in Vienna, Austria, from January 2000 to May 2020. 88 were male (78.6%), and the median age at diagnosis was 67.5 years.
• Exposure: Asbestos exposure was not recorded or analyzed. The study examined treatment, along with patient and tumor characteristics. Treatments were chemotherapy (cisplatin or carboplatin with pemetrexed, or platin with gemcitabine), surgery (extended pleurectomy/decortication, pleurectomy/decortication, or extrapleural pneumonectomy) and radiotherapy.
• Main results:
  • Surgery with curative intent: 40 patients had lung-preserving surgery (34 extended pleurectomy/decortication, 6 pleurectomy/decortication), and 9 had extrapleural pneumonectomy.
  • Whole cohort (112 patients): median overall survival was 16.9 months (95% CI 13.4 to 20.4). One-year survival was 64.1%, 3-year survival 19.8% and 5-year survival 13.1%.
  • Epithelioid subtype: median survival 20.3 months (95% CI 16.9 to 23.7). Biphasic or non-epithelioid subtypes: 6.8 months (95% CI 3.2 to 10.4). The difference was significant (p less than 0.001).
  • Patients who received surgery plus chemotherapy and/or radiotherapy had a median survival of 22.7 months (95% CI 17.2 to 28.2). Patients without additional oncological treatment had a median survival of 9.9 months (95% CI 6.7 to 13.1).
  • Ten patients completed trimodal therapy (neoadjuvant chemotherapy, surgery and adjuvant radiotherapy). Their median survival was 30.8 months (95% CI 7.2 to 54.4).
  • The results text gives these figures. Lung-preserving surgery (40 patients): median survival 25.5 months (95% CI 15.1 to 35.9). Extrapleural pneumonectomy (9 patients): median survival 12.3 months (95% CI 12.1 to 13.5). Table 4 prints different intervals for both groups.
  • After lung-preserving surgery, 3-year survival was 38.3% and 5-year survival 29.2%. After extrapleural pneumonectomy, 3-year survival was 0%.
  • Median survival by tumor stage was 42.3 months in Stage I, 18.1 months in Stage II, 17.4 months in Stage III and 8.5 months in Stage IV.
  • Postoperative complications occurred in 29 of 49 surgically treated patients (59.2%).
  • No patient died within 30 days of surgery.
  • In multivariate analysis, only epithelioid subtype and early tumor stage were significantly linked to better survival. Cardiac decompensation and arterial hypertension were significantly linked to worse survival.
• The authors' conclusion: The authors concluded that the optimal sequence of treatments is still unclear and that solid evidence is lacking. They suggested that adopting and strictly following a standardized institutional treatment algorithm might pave the way for universally accepted therapeutic standards.
• Limitations the authors state:
  • The survival benefit of multimodal therapy including surgery, seen in the univariate analysis, must be interpreted with caution. The adjusted analysis did not identify surgery as an independent factor, and the epithelioid subtype was more frequent in the surgery group.
  • The benefit of multimodal therapy may reflect selection bias, because surgery is reserved for the fittest patients in earlier stages.
  • Only nine patients had extrapleural pneumonectomy, and they had more advanced disease. The authors say the value of this operation cannot be judged reliably from their data.
  • No pathological grading data were available.
  • The study design was retrospective.
  • The complication reporting system is not universally accepted. The higher complication rates compared with other studies may therefore reflect wider reporting rather than more complications.
  • Treatment given after the disease came back was not analyzed.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Asbestos Exposure, Chemotherapy, Overall Survival, Multimodal Therapy, Palliative Care, Median Overall Survival, Epithelioid.

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