Preoperative assessment and therapeutic options for patients with malignant pleural mesothelioma

Our plain-English summary of Preoperative assessment and therapeutic options for patients with malignant pleural mesothelioma, by S. Paul, S. Neragi-Miandoab, M.T. Jaklitsch (Thoracic Surgery Clinics, 2004).

The study

• Authors: S. Paul, S. Neragi-Miandoab, M.T. Jaklitsch
• Journal: Thoracic Surgery Clinics
• Published: 2004;14(4):505-16, ix
• Type of article: Review
• Cited by: 7 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Prompt medical evaluation and aggressive treatment can lead to prolonged survival or successful palliation of symptoms for patients with malignant pleural mesothelioma, but the window for implementing treatment is short. Clinical recognition of the cancer is confounded by numerous factors, including long latency between exposure to asbestos and expression of the disease, nonspecific nature of the presenting symptoms, rarity of the disease, a lack of experience in clinical diagnosis, and rapidly deteriorating clinical course after diagnosis. Heightened clinical suspicion and proper patient selection through accurate staging and pathologic identification are paramount to defining and delivering therapy for this rare, lethal cancer.

In plain English

This article was a review by three thoracic surgeons at Brigham and Women's Hospital in Boston. It covered how malignant pleural mesothelioma is recognized, diagnosed, staged and treated, and described their own hospital's practice. It reported no new patient data. The authors noted that diagnosis is often delayed because early symptoms are nonspecific. They advocated diagnosis by biopsy of the pleura under direct vision with a thoracoscope, noting that testing of pleural fluid had low sensitivity in published series. They described how they chose between extrapleural pneumonectomy, a larger operation that removes the lung, and pleurectomy and decortication. Patients younger than 75 with preserved functional status were considered for the larger operation, and the authors listed blood-gas, heart and lung-function limits that ruled it out. They reported that, in their experience, the TNM staging system often did not predict prognosis for surgical patients. Asbestos exposure was raised as a reason to suspect the disease and to expect underlying pulmonary fibrosis. No fiber types were discussed. The authors concluded that caregivers must tailor treatment to balance its intensity against the patient's impairment.

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 the diagnosis, staging, preoperative evaluation and treatment of malignant pleural mesothelioma, combined with a description of the authors' own institutional approach; no new patient data
• Who was studied: No study population. The article discusses patients with malignant pleural mesothelioma in general, as referred for thoracic surgical consultation at the authors' institution (Brigham and Women's Hospital / Dana Farber Cancer Institute, Boston)
• Exposure: Not studied. Asbestos exposure is mentioned in two ways: as a history that should raise suspicion of mesothelioma, and as a reason underlying pulmonary fibrosis can be expected when assessing lung reserve before surgery. No fiber types, products, jobs or doses are discussed.
• Main results:
  • The authors advocated direct pleural biopsy by pleuroscopy for a definitive diagnosis. Citing other series, they noted that cytology of pleural fluid had a sensitivity of only 26% to 30%.
  • In discussing pulmonary function testing before surgery, the authors stated that because many patients with mesothelioma have been exposed to asbestos, underlying pulmonary fibrosis can be expected in this population.
  • The authors' exclusion criteria for extrapleural pneumonectomy (EPP) were: room-air arterial PCO2 more than 45 mm Hg, room-air arterial PO2 less than 65 mm Hg, cardiac ejection fraction less than 40%, and predicted postoperative FEV1 less than 1 L.
  • Patients younger than 75 with preserved functional status were considered for EPP. Elderly patients, those over 75, and those not meeting EPP criteria were offered pleurectomy and decortication (P/D).
  • The authors reported that, in their experience, the TNM staging system often did not accurately predict prognosis for patients treated with surgery. They described the Brigham staging system as an alternative.
  • Citing earlier work, the authors stated that EPP followed by chemoradiation currently offered the best therapeutic approach for patients deemed resectable.
  • For cachexia (severe weight loss), the authors reported modest success stabilizing weight in otherwise functional patients with oral thalidomide at 200 to 300 mg per day.
• The authors' conclusion: The authors concluded that caregivers must tailor an individual treatment plan that balances the magnitude of treatment against the patient's constitutional impairment. They stated that treatment had improved over the past 10 years but that much work remained.

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, Latency, Staging.

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