Multimodality treatment of malignant pleural mesothelioma

Our plain-English summary of Multimodality treatment of malignant pleural mesothelioma, by L. Berzenji, P. Van Schil (F1000Research, 2018).

The study

• Authors: L. Berzenji, P. Van Schil
• Journal: F1000Research
• Published: 2018;7
• Type of article: Review
• Cited by: 26 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant pleural mesothelioma (MPM) is a rare disease of the pleura and is largely related to asbestos exposure. Despite recent advancements in technologies and a greater understanding of the disease, the prognosis of MPM remains poor; the median overall survival rate is about 6 to 9 months in untreated patients. The main therapeutic strategies for MPM are surgery, chemotherapy, and radiation therapy (RT). The two main surgical approaches for MPM are extrapleural pneumonectomy (EPP), in which the lung is removed en bloc, and pleurectomy/decortication, in which the lung stays in situ. Chemotherapy usually consists of a platinum-based chemotherapy, such as cisplatin, often combined with a folate antimetabolite, such as pemetrexed. More recently, immunotherapy has emerged as a possible therapeutic strategy for MPM. Evidence suggests that single-modality treatments are not an effective therapeutic approach for MPM. Therefore, researchers have started to explore different multimodality treatment approaches, in which often combinations of surgery, chemotherapy, immunotherapy, and RT are investigated. There is still no definitive answer to the question of which multimodality treatment combinations are most effective in improving the poor prognosis of MPM. Research into the effects of trimodality treatment approaches have found that radical approaches such as EPP and hemithoracic RT post-EPP are less effective than was previously assumed. In general, there are still a great number of unanswered questions and unknown factors regarding the ideal treatment approach for MPM. Hopefully, more research into multimodality therapy will provide insight into which combination of treatment modalities is most effective.

In plain English

This article was a commissioned review, not a new study. The authors, from the Department of Thoracic and Vascular Surgery at Antwerp University Hospital in Belgium, described published and ongoing research on treating malignant pleural mesothelioma with surgery, chemotherapy, radiation therapy and immunotherapy, alone or combined. In one randomized trial they reviewed (MARS 1, by Treasure et al.), median overall survival was 14.4 months for patients assigned to extrapleural pneumonectomy, an operation that removes the lung, and 19.5 months for those given standard non-radical therapy. In a second randomized trial, median survival was about 20 months both with and without chest radiation after chemotherapy and extrapleural pneumonectomy. In a phase II study by Yamanaka et al. of three-part (trimodality) treatment, median survival was 39.4 months for the 17 of 42 enrolled patients who received it, and 19.9 months for all 42. The authors described a shift among surgeons toward lung-sparing pleurectomy/decortication. They concluded that even the randomized trials do not provide definite answers. They named poor, underpowered evidence and selection bias in surgical studies as problems.

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 (commissioned F1000 Faculty Review) of published and ongoing studies on treatment of malignant pleural mesothelioma
• Who was studied: No patients were studied directly. The review covered published clinical studies and ongoing trials of treatment for malignant pleural mesothelioma (MPM), including two randomized controlled trials of multimodality treatment.
• Exposure: The review is about treatments, not exposures: surgery (extrapleural pneumonectomy and pleurectomy/decortication), chemotherapy (mainly cisplatin with pemetrexed), radiation therapy and immunotherapy, alone and in combination. As background, it states that most MPM cases are related to exposure to amphibole asbestos.
• Main results:
  • Reviewed MARS 1 randomized trial (Treasure et al.): 50 patients were eligible for randomization, 24 to the EPP arm and 26 to standard therapy. Median overall survival was 14.4 months from randomization in the EPP arm and 19.5 months in the non-EPP arm. The EPP arm also had higher morbidity and more serious adverse events.
  • Reviewed second randomized trial (hemithoracic radiotherapy after neoadjuvant chemotherapy and EPP): 54 patients, 27 in the RT arm and 27 in the non-RT arm. Overall median survival was about 20 months in both groups.
  • Reviewed phase II trimodality study (Yamanaka et al.): 42 patients enrolled. Median survival was 39.4 months for the 17 who received trimodality therapy and 19.9 months for all 42. Those authors judged the risk-to-benefit ratio unsatisfactory.
  • Reviewed prospective study (Rea et al.) of 21 patients given induction chemotherapy, EPP and postoperative RT: median overall survival was 25.5 months.
  • Reviewed EORTC study: 59 patients enrolled, of whom 37 received trimodality therapy. That study judged trimodality treatment feasible in selected patients with early stage mesothelioma at institutions with high expertise.
  • The authors described a shift in surgeons' preference from EPP toward extended pleurectomy/decortication, which other studies associated with lower complication rates.
• The authors' conclusion: The authors concluded that even the randomized controlled trials do not provide definite answers about the best multimodality treatment and have added to the surgical controversy. They noted that ongoing trials using lung-sparing surgery may help define the roles of chemotherapy, RT and pleurectomy/decortication.
• Limitations the authors state:
  • The authors state that much of the published evidence on multimodal approaches is of poor quality and underpowered.
  • The authors state that selection bias is common in studies of surgery for MPM, because patients are chosen for surgery on criteria such as histology, performance status, age and tumor bulk.

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, Pleura, Asbestos Exposure, Prognosis, Median Overall Survival, Chemotherapy, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D).

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• Pretreatment serum C-reactive protein levels predict benefit from multimodality treatment including radical surgery in malignant pleural mesothelioma: a retrospective multicenter analysis — B. Ghanim, M.A. Hoda, et al. (2012)
• Multimodality treatment of pleural mesothelioma — D.D. Shersher, M.J. Liptay (2013)

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