Radical pleurectomy and intraoperative photodynamic therapy for malignant pleural mesothelioma

Our plain-English summary of Radical pleurectomy and intraoperative photodynamic therapy for malignant pleural mesothelioma, by J.S. Friedberg, M.J. Culligan, R. Mick, et al (The Annals of Thoracic Surgery, 2012).

The study

• Authors: J.S. Friedberg, M.J. Culligan, R. Mick, J. Stevenson, S.M. Hahn, D. Sterman, S. Punekar, E. Glatstein, K. Cengel
• Journal: The Annals of Thoracic Surgery
• Published: 2012;93(5):1658-65; discussion 1665-7
• Cited by: 115 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Radical pleurectomy (RP) for mesothelioma is often considered either technically unfeasible or an operation limited to patients who would not tolerate a pneumonectomy. The purpose of this study was to review our experience using RP and intraoperative photodynamic therapy (PDT) for mesothelioma.

Methods: Thirty-eight patients (42-81 years) underwent RP-PDT. Thirty five of 38 (92%) patients also received systemic therapy. Standard statistical techniques were used for analysis.

Results: Thirty seven of 38 (97%) patients had stage III/IV cancer (according to the American Joint Committee on Cancer [AJCC manual 7th Edition, 2010]) and 7/38 (18%) patients had nonepithelial subtypes. Macroscopic complete resection was achieved in 37/38 (97%) patients. There was 1 postoperative mortality (stroke). At a median follow-up of 34.4 months, the median survival was 31.7 months for all 38 patients, 41.2 months for the 31/38 (82%) patients with epithelial subtypes, and 6.8 months for the 7/38 (18%) patients with nonepithelial subtypes. Median progression-free survival (PFS) was 9.6, 15.1, and 4.8 months, respectively. The median survival and PFS for the 20/31 (64%) patients with N2 epithelial disease were 31.7 and 15.1 months, respectively.

Conclusions: It was possible to achieve a macroscopic complete resection using lung-sparing surgery in 97% of these patients with stage III/IV disease. The survival we observed with this approach was unusually long for the patients with the epithelial subtype but, interestingly, the PFS was not. The reason for this prolonged survival despite recurrence is not clear but is potentially related to preservation of the lung or some PDT-induced effect, or both. We conclude that the results of this lung-sparing approach are safe, encouraging, and warrant further investigation.

Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

In plain English

This retrospective review covered 38 patients with malignant pleural mesothelioma treated at the University of Pennsylvania from 2005 to 2010. Each had a lung-sparing operation the authors call radical pleurectomy. Surgery was combined with intraoperative photodynamic therapy, a laser-activated drug treatment. Most had advanced disease: 28 stage III and 9 stage IV. The article does not discuss asbestos exposure. All visible tumor was removed in 37 of 38 patients. One patient died after surgery, of a stroke. At a median follow-up of 34.4 months, median survival for all patients was 31.7 months (95% confidence interval, 9.0 to 54.3) and median progression-free survival was 9.6 months (95% CI, 6.8 to 12.4). Median survival was 41.2 months (95% CI, 25.9 to 56.4) for the 31 patients with the epithelial subtype and 6.8 months (95% CI, 4.7 to 8.9) for the 7 with nonepithelial subtypes. The authors noted that the study was small, retrospective and likely subject to selection bias. They also cautioned that only 7 patients had nonepithelial subtypes. They concluded the approach was promising and warranted further investigation.

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 review of a single-surgeon treatment series (case series); the first 14 patients came from an earlier pilot study and the next 24 were consecutive
• Who was studied: 38 patients with malignant pleural mesothelioma (median age 65, range 42 to 81; 28 men, 10 women) treated at the University of Pennsylvania, 2005 to 2010; 28 stage III, 9 stage IV, 1 stage I; 31 epithelial and 7 nonepithelial subtypes
• Exposure: Treatment studied, not an asbestos exposure: radical pleurectomy (lung-sparing surgery) plus intraoperative photodynamic therapy with intravenous porfimer sodium 2 mg/kg given 24 hours before surgery, activated by 630 nm laser light to 60 J/cm2; most patients also received pemetrexed-based chemotherapy. Asbestos exposure is not reported.
• Main results:
  • Macroscopic complete resection (removal of all visible tumor) was achieved in 37 of 38 patients (97%)
  • One patient died after surgery, from a stroke on postoperative day 4
  • Transient breathing failure requiring reintubation, attributed to photodynamic therapy, occurred in 6 of 38 patients
  • At a median follow-up of 34.4 months, median survival for all 38 patients was 31.7 months (95% CI, 9.0 to 54.3 months)
  • Median progression-free survival for all 38 patients was 9.6 months (95% CI, 6.8 to 12.4 months)
  • Median survival was 6.8 months (95% CI, 4.7 to 8.9) for the 7 patients with nonepithelial subtypes and 41.2 months (95% CI, 25.9 to 56.4) for the 31 patients with the epithelial subtype
  • Median progression-free survival was 4.8 months (95% CI, 4.4 to 5.3) for nonepithelial subtypes and 15.1 months (95% CI, 0.8 to 29.3) for the epithelial subtype
  • For the 20 of 31 epithelial patients with N2 lymph node disease, median survival was 31.7 months (95% CI, 12.5 to 50.9) and progression-free survival was 15.1 months (95% CI, 5.3 to 24.8)
  • For the 11 of 31 epithelial patients with N0 or N1 disease, median survival was 57.1 months (95% CI, 0 to 133.6). The authors reported this as statistically significantly different from the N2 group.
  • Of the 28 patients whose disease progressed, 10 had only local recurrence, 3 only distant, and 15 both local and distant
  • No difference in outcome was found by stage (28 stage III, 9 stage IV, 1 stage I patients)
• The authors' conclusion: The authors concluded that this lung-sparing approach to mesothelioma is promising and warrants further investigation
• Limitations the authors state:
  • The study was small, retrospective, and likely subject to selection bias
  • The subtype results should be viewed with caution because only 7 of 38 patients had nonepithelial subtypes

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, Mesothelioma, Pneumonectomy, Systemic Therapy, AJCC, Median Survival, Progression-Free Survival.

Related studies

• Photodynamic therapy and the evolution of a lung-sparing surgical treatment for mesothelioma — J.S. Friedberg, R. Mick, et al. (2011)
• Phase III randomized trial of surgery with or without intraoperative photodynamic therapy and postoperative immunochemotherapy for malignant pleural mesothelioma — H.I. Pass, B.K. Temeck, et al. (1997)
• A preclinical model to investigate the role of surgically-induced inflammation in tumor responses to intraoperative photodynamic therapy — R.W. Davis, E. Papasavvas, et al. (2018)
• Photodynamic therapy for mesothelioma — S.M. Hahn, R.P. Smith, et al. (2001)
• Photodynamic therapy for malignant pleural mesothelioma: the future of treatment? — J.S. Friedberg (2011)
• A Novel Prospective Study Assessing the Combination of Photodynamic Therapy and Proton Radiation Therapy: Safety and Outcomes When Treating Malignant Pleural Mesothelioma — S.R. Rice, Y.R. Li, et al. (2019)

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