Multimodality therapy for malignant mesothelioma based on a study of natural history

Our plain-English summary of Multimodality therapy for malignant mesothelioma based on a study of natural history, by K.H. Antman, R.H. Blum, J.S. Greenberger, et al (The American Journal of Medicine, 1980).

The study

• Authors: K.H. Antman, R.H. Blum, J.S. Greenberger, G. Flowerdew, A.T. Skarin, G.P. Canellos
• Journal: The American Journal of Medicine
• Published: 1980;68(3):356-62
• Cited by: 192 articles, as counted by NIH iCite
• Read it: PubMed · Publisher
• In J-M's library: Johns-Manville's company medical library held a copy.

In plain English

The authors reviewed all 40 patients with tissue-confirmed malignant mesothelioma (34 pleural, six peritoneal) treated at two Boston institutions between 1965 and 1978. Twenty-five (63 per cent) reported asbestos exposure or shipyard work where asbestos was used. Women, patients with limited disease, and patients with symptoms for more than six months before diagnosis survived significantly longer. No prognostic significance was found for smoking, asbestos exposure, tissue subtype, or pleural versus peritoneal disease. Ten patients with an attempted tumor resection had a median survival of 15 months, versus 8.5 months for 24 who had only a biopsy. Nine of 22 previously untreated patients given Adriamycin-containing regimens had a partial response. Among patients whose cause of death could be evaluated, 78 per cent died of complications of the local tumor. The authors concluded that mesothelioma differs enough from sarcoma to be treated as a separate disease. They recommended that otherwise healthy patients with disease in one side of the chest be offered maximal surgery, then radiation to remaining tumor, then Adriamycin-containing chemotherapy. They noted that treatment groups were not directly comparable.

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: Case series: an analysis of all patients with mesothelioma treated at two Boston institutions. It assessed clinical features related to survival and the results of treatment. From 1975, some patients were treated prospectively on one chemotherapy regimen.
• Who was studied: 40 patients with histologically confirmed malignant mesothelioma, treated at the Sidney Farber Cancer Institute and the Peter Bent Brigham Hospital, Boston, between 1965 and 1978.
• 31 men and nine women, aged 10 to 82 years (median 53).
• 34 had pleural and six had peritoneal disease.
• The benign solitary variant was excluded.
• Exposure: Asbestos exposure reported by patients, including shipyard employment (no fiber type named).
• Eleven patients were exposed for less than five years, generally in World War II naval shipyards.
• Eight had 20 to 30 years of occupational contact.
• Three young patients with pleural disease had fathers occupationally exposed to asbestos. The authors presumed these three were exposed in childhood via work clothes.
• Time from first exposure to symptoms was 12 to 38 years (median 32).
• 82 per cent of patients had a history of cigarette smoking.
• Main results:
  • Three groups survived significantly longer: women, patients who presented with limited disease, and patients with symptoms for more than six months before diagnosis.
  • The nine women had a median survival of 32.3 months (32.2 in Table I), about three and a half times that of the 31 men (9.0 months). All women presented with limited disease.
  • Survival by stage of disease:
• Stage I (31 patients, disease confined to one pleural cavity or the peritoneum): median survival 16 months, and 40 per cent survived two years.
• Stage II (four patients): median survival nine months.
• Stage III (five patients): none survived one year.
  • Patients whose first symptom was dyspnea had a median survival of 14.2 months, versus 7.8 months for those whose first complaint was chest pain (p-value printed as 0.32). The body text gives different figures: 22 months for 11 patients with shortness of breath versus 8.5 months for 18 with pain.
  • No prognostic significance was found for smoking history, asbestos exposure, pathologic subtype, or pleural versus peritoneal presentation. An apparent longer survival for the epithelial subtype was not statistically significant.
  • The 10 patients who underwent subtotal or attempted total resection had a median survival of 15 months. The 24 who had only an open biopsy had a median survival of 8.5 months.
  • Five patients received aggressive radiotherapy with curative intent: four after subtotal resection and one after biopsy. They survived a median of 9.21 months, and one patient was disease-free at 52 months.
  • Chemotherapy responses:
• Nine of 22 (40 per cent) previously untreated patients had a partial response to Adriamycin-containing regimens.
• Previously treated patients did not respond to a second regimen.
• Of 14 patients treated from 1975 with Adriamycin, cyclophosphamide and DTIC, five (36 per cent) had a partial remission, with a median duration of 10 months.
  • The 29 patients who received chemotherapy survived a median of 15 months. The five patients (four with limited disease) who accepted only supportive care survived a median of 4.2 months.
  • Among patients whose cause of death could be evaluated, 78 per cent died of direct complications of local disease, such as respiratory failure or bowel obstruction. Cause of death was not available for eight of the 31 who had died. Distant metastases were found at autopsy in only four patients.
• The authors' conclusion: The authors concluded that mesothelioma is different enough from sarcoma to justify treating it as a separate disease. They recommended that otherwise healthy patients with disease limited to one side of the chest be offered three steps in order: maximal tumor resection, then postoperative radiation to areas of residual disease, then an Adriamycin-containing chemotherapy regimen.
• Limitations the authors state:
  • Most initial operations were done in community hospitals, so no uniform criteria for surgical resection were applied.
  • Survival with single treatments cannot be directly compared with survival with combined treatments, because patients with extensive disease were more likely to receive multiple treatments.

Topics

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

Medical terms in this study, explained in our Lexicon: Multimodal Therapy, Malignant Mesothelioma.

Related studies

• Peritoneal mesothelioma: natural history and response to chemotherapy — K.H. Antman, E.A. Pomfret, et al. (1983)
• Role of integrated 18-fluorodeoxyglucose position emission tomography-computed tomography in patients surveillance after multimodality therapy of malignant pleural mesothelioma — C. Tan, S. Barrington, et al. (2010)
• Radiation therapy in the management of patients with mesothelioma — W. Gordon, K.H. Antman, et al. (1982)
• Multicystic peritoneal mesothelioma in an octogenarian: diagnosis, natural history, and treatment — C.M. Psoinos, D. Kandil, et al. (2012)
• Natural history and epidemiology of malignant mesothelioma — K.H. Antman (1993)
• Natural history and staging of malignant mesothelioma — K.H. Antman (1989)

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