Preoperative Identification of Benefit from Surgery for Malignant Pleural Mesothelioma

Our plain-English summary of Preoperative Identification of Benefit from Surgery for Malignant Pleural Mesothelioma, by I. Opitz, K. Furrer (Thoracic Surgery Clinics, 2020).

The study

• Authors: I. Opitz, K. Furrer
• Journal: Thoracic Surgery Clinics
• Published: 2020;30(4):435-449
• Type of article: Review
• Cited by: 11 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

In the absence of standardized treatment algorithms for patients with malignant pleural mesothelioma, one of the main difficulties remains patient allocation to therapies with potential benefit. This article discusses clinical, radiologic, pathologic, and molecular prognostic factors as well as genetic background leading to preoperative identification of benefit from surgery, which have been investigated over the past years to simplify and at the same time specify patient selection for surgical treatment.

Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.

In plain English

This article was a narrative review of published research on how to identify, before an operation, which patients with malignant pleural mesothelioma might benefit from surgery. The article describes this disease of the chest cavity as associated with asbestos exposure. The review covered age, gender, fitness, blood tests, imaging and staging, response to chemotherapy, tumor subtype, molecular markers and combined prognostic scores. Among the studies reviewed, an Italian multicenter analysis found that having no history of asbestos exposure was one of several independent predictors of long-term survival after surgery. A study of the SEER cancer database found that surgery was associated with improved survival in the epithelioid subtype but not in the biphasic or sarcomatoid subtypes. The authors described their own earlier score, which combined tumor volume, tumor subtype, C-reactive protein and chemotherapy response. Patients scoring 3 or 4 had a median survival of 4 months. The authors noted that most markers and scores still lack independent validation. They concluded that surgery within a multimodality approach should still be offered to appropriately selected patients in high-volume, low-mortality centers.

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 studies and guidelines on preoperative prognostic factors and scores for surgery in malignant pleural mesothelioma. It includes some of the authors' own earlier and unpublished data.
• Who was studied: Not a single study population. The review covers published studies of patients with malignant pleural mesothelioma being considered for surgery.
• Exposure: The review did not study an exposure. It describes malignant pleural mesothelioma as associated with asbestos exposure, and some of the reviewed studies examined a history of asbestos exposure as a prognostic factor. No fiber types are named.
• Main results:
  • In an Italian multicenter analysis cited by the review, independent predictors of long-term survival after surgery were: younger age (OR 0.51, 95% CI 0.31–0.82), epithelioid histology (OR 7.07, 95% CI 1.56–31.93), no history of asbestos exposure (OR 3.13, 95% CI 1.13–8.66), and a ratio of metastatic to resected lymph nodes below 22% (OR 4.12, 95% CI 1.68–10.12).
  • In the IASLC database analyses cited by the review (Pass, Rusch and colleagues), median overall survival was 17 months in patients with no history of asbestos exposure and 15 months in patients with such a history.
  • In a SEER database study cited by the review (Meyerhoff and colleagues), median survival was 19 months for epithelioid, 12 months for biphasic and 4 months for sarcomatoid histology. In multivariate analysis, surgery was associated with improved survival in the epithelioid group (HR 0.72, P less than .01) but not in the biphasic (HR 0.73, P = .19) or sarcomatoid (HR 0.79, P = .18) groups.
  • The authors' own multimodality prognostic score (MMPS, defined in their earlier publication) combined four items: tumor volume above 500 mL before chemotherapy, nonepithelioid subtype, CRP above 30 mg/L before chemotherapy, and progressive disease after chemotherapy. Median overall survival was 34, 17 and 12 months for scores of 0, 1 and 2.
  • Patients with an MMPS score of 3 or 4 had a median overall survival of 4 months. The authors reported that the score was further validated in an independent cohort from Vienna.
  • In unpublished data from the authors' group on 218 patients, progressive disease after induction treatment was associated with a higher risk of dying than stable disease (HR 1.5496089, CI 1.0230936 to 2.347085, P = .04). Partial regression did not appear more beneficial than stable disease (HR 0.9067194, P = .58).
• The authors' conclusion: The authors concluded that, in appropriately selected patients with an acceptable risk profile, surgical resection (extended P/D, P/D, or EPP) as part of a multimodality concept should still be offered if performed in high-volume, low-mortality centers. They also concluded that a combination of several factors seems the most appropriate tool for deciding on surgery.
• Limitations the authors state:
  • Most of the molecular and blood markers discussed have not yet been independently and prospectively validated.
  • Most prognostic scores lack validation in independent cohorts.
  • Staging by imaging often correlates poorly with staging by pathology.

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.

Related studies

• Preoperative computed tomography does not predict resectability in peritoneal carcinomatosis — J.D. Rivard, W.J. Temple, et al. (2014)
• Surgery in the treatment of malignant pleural mesothelioma: recruitment into trials should be the default position — A. Datta, R. Smith, et al. (2014)
• The new case for cervical mediastinoscopy in selection for radical surgery for malignant pleural mesothelioma — A. Nakas, D. Waller, et al. (2012)
• Outcomes of Cytoreductive Surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients older than 70 years; survival benefit at considerable morbidity and mortality — K.I. Votanopoulos, N.A. Newman, et al. (2013)
• 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)
• Repeat cytoreductive surgery and heated intraperitoneal chemotherapy may offer survival benefit for intraperitoneal mesothelioma: a single institution experience — J. Wong, A.L. Koch, et al. (2014)

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