Multimodality approach in management of malignant pleural mesothelioma

Our plain-English summary of Multimodality approach in management of malignant pleural mesothelioma, by S. Neragi-Miandoab (European Journal of Cardio-thoracic Surgery, 2006).

The study

• Author: S. Neragi-Miandoab
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2006;29(1):14-9
• Type of article: Review
• Cited by: 30 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Malignant pleural mesothelioma (MPM) is a solid, locally aggressive tumor, which has been closely linked to asbestos exposure. The survival rate without treatment ranges from 4 to 12 months. Response to chemotherapy and radiation is poor, and surgery is the most effective therapy. There are currently 3000 new MPM cases per year in the United States, with the peak incidence in the United States and Europe expected to occur in the year 2020. The prognosis depends on the stage of the tumor at the time of diagnosis, its histological type, lymph node status, and resection margins. While the diagnosis is often delayed, earlier intervention may improve life expectancy. Single-modality therapy has not been effective in changing the natural history of MPM. As a result, multimodality regimens involving surgery with radiation, chemotherapy, or immunotherapy have been initiated. Multiple modality approach has demonstrated favorable outcome, particularly in patients with epithelial histology, negative resection margins and presence of no metastases to extrapleural lymph nodes. Cisplatin and mitomycin have demonstrated modest efficacy in management of distant tumor recurrence. Cisplatin and gemcitabine regimen as well as cisplatin/pemetrexed followed by 54 Gy of adjuvant hemithorax radiation have been reported to improve the outcome.

In plain English

This single-author narrative review, with no new patient data, covered published studies of surgery, radiation and chemotherapy, alone or combined, for malignant pleural mesothelioma, a cancer the article describes as closely linked to asbestos exposure. One Sugarbaker et al. series found a median survival of 51 months in patients with epithelial-type, stage I disease and negative lymph nodes. A later Sugarbaker et al. series of 328 patients having extrapleural pneumonectomy (removal of the lung and its lining) reported 3.8% mortality around the time of surgery and 25% overall complications. In a Baldini et al. study, local recurrence was 31% with radiation and 45% without, a difference not statistically significant. A phase III trial was described as comparing pemetrexed plus cisplatin with cisplatin alone. The combination's response rate was 41.3%, versus 16.7% in a group the review calls the 'control group', a label it also gives eight untreated patients. The author noted that no randomized trials had compared the surgical or follow-up treatment approaches. The author concluded that combined treatment significantly benefited selected patients and that aggressive surgery followed by chemotherapy and radiation was currently the best approach.

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 published treatment studies (no new patient data)
• Who was studied: Published studies of patients with malignant pleural mesothelioma treated with surgery, radiation, chemotherapy or combinations; the review itself studied no patients
• Exposure: Asbestos exposure was not studied. It is mentioned only as background; the review is about treatments (surgery, radiation, chemotherapy)
• Main results:
  • In a Sugarbaker et al. series cited by the review, a subgroup with epithelial histology, stage I disease and negative lymph nodes had a median survival of 51 months
  • In the review's section on perioperative mortality, Sugarbaker et al. reported 3.8% mortality and 25% overall morbidity in 328 patients undergoing extrapleural pneumonectomy, which the review takes as suggesting the operation is safe; this is mortality around the time of the operation, not overall deaths from mesothelioma. An earlier Butchart et al. report had given 30% mortality for the operation
  • In a study by Baldini et al., local recurrence occurred in 31% of patients treated with radiation versus 45% without; the difference was not statistically significant
  • Rusch et al., using 54 Gy hemithorax radiation after surgery, reported a 13% local recurrence rate, with 4% local-only recurrence
  • In a randomized trial of radiation to biopsy and thoracoscopy sites, none of 20 radiated patients developed metastases at those sites, compared with 8 of 20 control patients
  • A phase III trial was described as comparing pemetrexed plus cisplatin with cisplatin alone. Pemetrexed plus cisplatin had a response rate of 41.3% versus 16.7% in a group the review calls the 'control group'. The review also uses that label for 8 untreated patients and does not explicitly assign the 16.7% to the cisplatin-alone arm. Median survival was 12.1 versus 9.3 months
• The authors' conclusion: The author concluded that multimodality treatment is becoming more common, safe and effective, and gives a significant benefit and better outcome in selected patients. The author also concluded that aggressive cytoreduction followed by chemotherapy and radiation is currently the best approach.
• Limitations the authors state:
  • The author notes that no randomized trials had evaluated the various surgical or adjuvant treatment approaches
  • The author notes that the adjuvant treatment trials aimed at reducing local recurrence were not randomized

Topics

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

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Asbestos Exposure, Chemotherapy, Prognosis, Life Expectancy, Immunotherapy, Histology, Cisplatin.

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• Chemotherapy management of malignant pleural mesothelioma: a phase II study comparing two popular chemotherapy regimens — E.E. Habib, E.S. Fahmy (2013)
• In vitro anti-mesothelioma activity of cisplatin-gemcitabine combinations: evidence for sequence-dependent effects — I. Zanellato, C.D. Boidi, et al. (2011)
• Multimodality treatment of malignant pleural mesothelioma with or without immunotherapy: does it change anything? — M. Lucchi, A. Picchi, et al. (2010)
• Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma — L. Lang-Lazdunski, A. Bille, et al. (2012)

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