Node status has prognostic significance in the multimodality therapy of diffuse, malignant mesothelioma

Our plain-English summary of Node status has prognostic significance in the multimodality therapy of diffuse, malignant mesothelioma, by D.J. Sugarbaker, G.M. Strauss, T.J. Lynch, et al (Journal of Clinical Oncology, 1993).

The study

• Authors: D.J. Sugarbaker, G.M. Strauss, T.J. Lynch, W. Richards, S.J. Mentzer, T.H. Lee, J.M. Corson, K.H. Antman
• Journal: Journal of Clinical Oncology
• Published: 1993;11(6):1172-8
• Cited by: 185 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Purpose: We studied a multimodality approach using extrapleural pneumonectomy, chemotherapy, and radiotherapy in patients with malignant pleural mesothelioma.

Patients And Methods: From 1980 to 1992, 52 selected patients, underwent treatment. Median age was 53 years (range, 33 to 69). Initial patient evaluation was performed by a multimodality team. Pathologic diagnosis was reviewed and confirmed before therapy. Patients with no medical contraindication and potentially resectable mesothelioma on computed tomography (CT) (magnetic resonance imaging [MRI] when it became available) received extrapleural pneumonectomy, cyclophosphamide, doxorubicin, and cisplatin (CAP) chemotherapy, and radiotherapy.

Results: Perioperative morbidity and mortality rates were 17% and 5.8%, respectively. The overall median survival duration is 16 months (range, 1 month to 8 years). The 32 patients with epithelial histologic variant had 1-, 2-, and 3-year survival rates of 77%, 50%, and 42%, respectively. Patients with mixed and sarcomatous cell disease had 1- and 2-year survival rates of 45% and 7.5%; no patient lived longer than 25 months (P < .01). At resection, positive regional mediastinal lymph nodes were found in 13. Positive lymph nodes were associated with poorer survival than were negative nodes (P < .01). Patients with epithelial variant and negative mediastinal lymph nodes had a survival rate of 45% at 5 years.

Conclusion: Multimodality therapy including extrapleural pneumonectomy has acceptable morbidity and mortality for selected patients. Prolonged survival occurred in patients with epithelial histologic variant and negative mediastinal lymph nodes. These data provide a rationale for a revised staging system for malignant pleural mesothelioma; furthermore, they permit stratification of patients into groups likely to benefit from aggressive multimodality treatment.

In plain English

This study described 52 consecutive patients with malignant pleural mesothelioma operated on at Brigham and Women's Hospital, Boston, 1980 to 1992. All had extrapleural pneumonectomy. Of the 49 who survived surgery, 46 then received chemotherapy (doxorubicin and cyclophosphamide, with cisplatin added after 1985) and radiotherapy. All were judged fit and resectable on scans. Forty (77%) had an identifiable history of asbestos exposure; fiber types were not reported. Three (5.8%) died after surgery and nine (17%) had complications. Median survival was 16 months. The 32 with epithelial tumors had 1-, 2- and 3-year survival of 77%, 50% and 42%. The 20 with sarcomatous or mixed tumors had 1- and 2-year survival of 45% and 7.5%. The 13 with tumor in mediastinal lymph nodes had 1- and 2-year survival of 41% and 0%, against 71% and 46% for the 39 without. Asbestos exposure, age, sex and smoking were not significantly associated with survival. The authors concluded this treatment may extend survival in selected patients with epithelial, node-negative disease. They proposed a revised staging system, which they said needs confirmation in an independent data base.

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-institution case series of patients given a multimodality treatment program (surgery, chemotherapy, radiotherapy), with survival analysed by life tables, log-rank tests and Cox regression
• Who was studied: 52 consecutive selected patients with malignant pleural mesothelioma who underwent extrapleural (pleural) pneumonectomy at Brigham and Women's Hospital, Boston, 1980 to 1992; median age 53 years (range 33 to 69)
• Exposure: Treatment studied: extrapleural pneumonectomy in all 52 patients. Of the 49 who survived surgery, 46 then received doxorubicin and cyclophosphamide chemotherapy (cisplatin added after 1985) and 55 Gy radiotherapy. Asbestos exposure was recorded as a patient characteristic: 40 of 52 (77%) had an identifiable history of asbestos exposure. Fiber types were not reported.
• Main results:
  • Three of the 52 patients (5.8%) died after surgery
  • 49 patients survived surgery (the article gives their mean postoperative hospital stay)
  • Nine patients (17%) had perioperative complications
  • Overall median survival for all 52 patients was 16 months (range 1 month to 8 years)
  • The 32 patients (61%) with epithelial cell type had 1-, 2- and 3-year survival rates of 77%, 50% and 42%
  • The 20 patients with sarcomatous or mixed cell type had 1- and 2-year survival rates of 45% and 7.5% (P = .01 in the results text). None lived longer than 25 months.
  • The 39 patients (75%) without regional mediastinal nodal involvement had 1- and 2-year survival rates of 71% and 46%
  • The 13 patients with nodal involvement had 1- and 2-year survival rates of 41% and 0% (P less than .05)
  • Node status significantly predicted survival even within the epithelial and nonepithelial groups. Among the 32 patients with epithelial tumors, the seven with positive mediastinal nodes had significantly poorer survival (P less than .05).
  • In this group of selected patients, age, sex, cigarette-smoking history, asbestos exposure, length of operation and side of tumor were not significantly associated with survival. Gross residual tumor, tumor at the surgical margin, pericardial involvement (P = .19) and diaphragm involvement (P = .37) also did not significantly affect survival.
• The authors' conclusion: The authors concluded that aggressive multimodality treatment may extend survival in selected patients with epithelial, node-negative disease. They stated that extrapleural pneumonectomy had acceptable morbidity and mortality in selected patients. They proposed a revised staging system that treats node-positive resectable disease as a separate stage.
• Limitations the authors state:
  • The proposed staging system was based on one institution's data base. The authors said confidence in its correlation with prognosis would require confirmation in a second, independent data base.
  • The authors acknowledged that the relatively good results might reflect bias from small patient numbers or from selecting patients destined to do well. They judged this unlikely.
  • Disease-free survival was not calculated because most patients had gross or microscopic disease after surgery. Time to progression was also considered unreliable.

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, Malignant Mesothelioma, Extrapleural Pneumonectomy (EPP), Chemotherapy, Pleural Mesothelioma, Mesothelioma, Doxorubicin, Cisplatin.

Related studies

• A New Prognostic Score Supporting Treatment Allocation for Multimodality Therapy for Malignant Pleural Mesothelioma: A Review of 12 Years' Experience — I. Opitz, M. Friess, et al. (2015)
• Lymph node metastases in diffuse malignant peritoneal mesothelioma — D. Baratti, S. Kusamura, et al. (2010)
• 18F-FDG PET/CT in the management of patients with malignant pleural mesothelioma being considered for multimodality therapy: experience of a tertiary referral center — H.S. Elliott, U. Metser, et al. (2018)
• 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)
• Multimodality treatment of diffuse malignant pleural mesothelioma — L.S. Zellos, D.J. Sugarbaker (2002)
• Extrapleural and cardiophrenic lymph nodes: prevalence, clinical significance and diagnostic value — B. Feragalli, C. Mantini, et al. (2014)

Browse more research in Journal of Clinical Oncology, or return to medical research.