Prognostic factors in malignant pleural mesothelioma: a retrospective study of 60 Turkish patients

Our plain-English summary of Prognostic factors in malignant pleural mesothelioma: a retrospective study of 60 Turkish patients, by A. Koyuncu, D. Koksal, O. Ozmen, et al (Journal of Cancer Research and Therapeutics, 2015).

The study

• Authors: A. Koyuncu, D. Koksal, O. Ozmen, F. Demirag, H. Bayiz, K. Aydogdu, M. Berkoglu
• Journal: Journal of Cancer Research and Therapeutics
• Published: 2015;11(1):216-22
• Cited by: 10 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Aim: Malignant pleural mesothelioma (MPM) is an aggressive tumor with poor prognosis. The study aims to examine the effect of certain clinical, laboratory, radiologic, and pathologic characteristics on survival.

Patients And Methods: Sixty patients who had undergone PET/CT evaluation at initial diagnosis were included. We investigated the effect of certain clinical, laboratory, radiologic characteristics, SUVmax of the tumor, and pathological characteristics such as histological subtype, mitotic activity index (MAI), tumor necrosis, and inflammation on survival. The pathological slides of each patient were re-evaluated for MAI, presence of necrosis, and inflammation. The patients were grouped based on number of mitosis as MAI 1:≤ 9, MAI 2:10-19, MAI 3: >19 mitosis.

Results: There were 34 male and 26 female patients with a mean age of 53.6 ± 10.6 years. Mean and median survival time was 14.83 ± 10.75 and 11.95 (min 0.43-max 48.10) months, respectively. Using univariate analysis leukocytosis (P = 0.009), rind-like pleural thickening (P = 0.037), advanced disease stage (P = 0.004), best supportive therapy alone (P = 0.004), SUVmax higher than 8 (P = 0.023), MAI higher than 1 (P = 0.033), and presence of tumor necrosis (P = 0.037) were found as poor prognostic factors. At multivariate analysis, leukocytosis (P = 0.026, HR: 2.27), advanced disease stage (P = 0.021, HR: 2.46), best supportive therapy alone (P = 0.029, HR: 5.12), and MAI higher than 1 (P = 0.01, HR: 3.01) were independently associated with survival, whereas SUVmax of the tumor failed to enter the model (P = 0.07, HR: 1.89).

Conclusion: Presence of leukocytosis, advanced disease stages, supportive therapy alone, and higher MAI were found to be negative prognostic factors in patients with MPM.

In plain English

This retrospective study reviewed 60 patients (34 men, 26 women) with malignant pleural mesothelioma who had PET/CT staging scans at a Turkish medical center between November 2008 and December 2012. Environmental asbestos exposure was recorded in 88.3%; none was listed as occupational. The authors re-examined tissue slides, counting dividing tumor cells (the mitotic activity index, MAI). By the end of the study 40 patients had died, and median survival was 11.95 months. Analysed together, factors independently associated with poorer survival were white blood cell count above 10x10^3/ml (hazard ratio 2.27, 95% CI 1.101 to 4.699), stage 3 to 4 versus 1 to 2 (2.46; 1.143 to 5.315), best supportive care alone versus multimodality therapy (5.12; 1.112 to 23.57), and MAI grade 2 to 3 versus 1 (3.012; 1.305 to 6.953). A high PET reading (SUVmax above 8) and tumor necrosis were linked to shorter survival only when each factor was tested alone. Tumor histology was not a significant factor. The authors named the retrospective design and small sample size as limitations and called for prospective studies of MAI.

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 study of patient records, with PET/CT scans and pathology slides re-evaluated blind to clinical data; survival analysed by Kaplan-Meier, log rank test and multiple Cox regression
• Who was studied: 60 patients (34 male, 26 female; mean age 53.6 ± 10.6 years, range 27 to 77) diagnosed with malignant pleural mesothelioma who underwent PET/CT for staging between November 1, 2008 and December 31, 2012 at the authors' medical center in Turkey
• Exposure: Environmental exposure to asbestos in 53 patients (88.3%); no exposure in 7 (11.7%); the table lists no patients with occupational exposure. Fiber types are not stated. The study's main focus was prognostic factors, not exposure.
• Main results:
  • Of the 60 patients, 40 had died by the end of the study. Mean survival was 14.83 ± 10.75 months and median survival was 11.95 months (range 0.43 to 48.10).
  • For all patients, survival rates were 90.8% at 6 months, 58.6% at 1 year and 20.4% at 2 years.
  • By treatment, median survival was 35.2 months for the 7 patients given multimodality therapy, 14.8 months for the 38 given chemotherapy, and 5 months for the 15 given best supportive care. The authors attributed part of this to patient selection: best supportive care was used for disabled patients with advanced disease, and multimodality therapy for patients with good performance status and early-stage disease.
  • When each factor was tested alone, these were poor prognostic factors: leukocytosis (P = 0.009), rind-like pleural thickening (P = 0.037), advanced disease stage (P = 0.004), best supportive therapy alone (P = 0.004), SUVmax higher than 8 (P = 0.023), MAI higher than 1 (P = 0.033), and tumor necrosis (P = 0.037).
  • In multivariate analysis, leukocyte count above 10x10^3/ml compared with 10x10^3/ml or less (HR 2.27, 95% CI 1.101 to 4.699, P = 0.026) and stage 3 to 4 compared with stage 1 to 2 (HR 2.46, 95% CI 1.143 to 5.315, P = 0.021) were independently associated with poor prognosis.
  • In multivariate analysis, best supportive therapy alone, compared with multimodality therapy as the reference group, was independently associated with poor prognosis (HR 5.12, 95% CI 1.112 to 23.57, P = 0.029). Chemotherapy compared with multimodality therapy had an HR of 1.89.
  • MAI 2 to 3 compared with MAI 1 was independently associated with poor prognosis (HR 3.012, 95% CI 1.305 to 6.953, P = 0.01).
  • SUVmax above 8 did not reach statistical significance in the multivariate model (HR 1.89, 95% CI 0.95 to 3.762, P = 0.07).
  • Tumor necrosis was associated with poor prognosis when tested alone but was not an independent prognostic factor in multivariate analysis.
  • Tumor histology (45 epithelial, 14 biphasic, 1 undifferentiated) was not a significant prognostic factor. Median survival was 14 months in the epithelioid group and 12 months in the non-epithelioid group.
  • Age, gender and thrombocyte (platelet) counts were not found to be prognostic factors. Inflammation and pleurodesis were also not associated with survival.
• The authors' conclusion: The authors concluded that high leukocyte count, advanced disease stage, best supportive therapy alone and higher MAI were independent predictors of poor survival in patients with malignant pleural mesothelioma. They stated that MAI can be an important, easy and inexpensive tumor-related prognostic factor, and that prospective studies are required to validate it.
• Limitations the authors state:
  • Retrospective design and small sample size.
  • Because the study was retrospective, some factors such as performance status and chest pain were not investigated.
  • The lack of a significant effect of histology may be due to the small number of non-epithelioid cases.
  • SUVmax may have failed to reach independent significance partly because of the small number of patients.

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, Prognosis, Histological Subtype, Necrosis, Inflammation, Median Survival, Pleural Thickening, Multivariate Analysis.

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