SMART or simply bold?

Our plain-English summary of SMART or simply bold?, by V.W. Rusch, A. Rimner, P.S. Adusumilli (The Journal of Thoracic and Cardiovascular Surgery, 2016).

The study

• Authors: V.W. Rusch, A. Rimner, P.S. Adusumilli
• Journal: The Journal of Thoracic and Cardiovascular Surgery
• Published: 2016;151(2):476-7
• Type of article: Editorial, Comment
• Cited by: 4 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Summary of the article

This editorial commentary discussed a study by de Perrot and colleagues at the University of Toronto, published in the same issue, which reported expanded phase II experience with the Surgery for Mesothelioma After Radiation Therapy (SMART) regimen for malignant pleural mesothelioma (MPM). In that regimen, intensity-modulated radiation therapy with a high dose per fraction was given before extrapleural pneumonectomy (EPP). This shortened radiation from about 6 weeks to 5 days. The commentators noted that all 62 patients completed the planned treatment. Operative mortality was 1.6%, overall treatment-related mortality was 4.8%, there were no bronchial stump leaks, and only 4 resections were incomplete (R2). Median overall survival was 36 months on an intention-to-treat basis and 51 months for patients with epithelioid histologic type. The authors described several challenges: careful patient selection, the difficulty of predicting resectability with current staging, the need for EPP shortly after radiation to avoid life-threatening radiation pneumonitis, and the need for high-volume expert centers. They suggested that EPP may still have a role in selected patients with epithelioid tumors and no nodal metastases. They also raised the possibility that preoperative radiation affects immune response and thereby survival. They concluded that the results should be corroborated at a few other expert centers. In their view, studies of radiation and immune response would likely be more productive than a randomized trial of uncertain feasibility.

PubMed has no abstract for this study, and the article doesn't print one. We wrote this summary from the full article with the help of AI. It is not the authors' wording.

In plain English

This was an editorial commentary, not an original study. The authors commented on a separate study by de Perrot and colleagues at the University of Toronto, published in the same journal issue, about the SMART regimen for malignant pleural mesothelioma. In that regimen, high-dose radiation over 5 days was given before an operation called extrapleural pneumonectomy. As the authors described it, the Toronto study reported that all 62 patients completed the planned treatment. Operative mortality was 1.6% and overall treatment-related mortality was 4.8%. Median overall survival was 36 months for all patients and 51 months for patients with the epithelioid tumor type. The authors noted that patient selection was critical and that only high-volume centers could potentially reproduce these results. They also asked whether the results reflected patient selection or the treatment itself. They suggested that preoperative radiation might be affecting immune response in some patients. The authors concluded that the results could be checked at a few other expert centers, and that immune studies would likely be more productive than a randomized trial of uncertain feasibility.

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: Editorial commentary on another study (de Perrot and colleagues, SMART regimen); no new data were collected
• Who was studied: No population was studied by these authors. The commentary discusses a phase II study from the University of Toronto of 62 patients with malignant pleural mesothelioma treated with the SMART regimen.
• Exposure: No asbestos exposure is discussed. The subject is a treatment: preoperative high-dose intensity-modulated radiation therapy given over 5 days, followed by extrapleural pneumonectomy.
• Main results:
  • As described by the authors, in the Toronto study all 62 patients completed the planned treatment, and operative mortality was 1.6%.
  • As described by the authors, overall treatment-related mortality in the Toronto study was 4.8%.
  • As described by the authors, median overall survival in the Toronto study was 36 months for all patients on an intention-to-treat basis, and 51 months for patients with the epithelioid histologic type.
  • As described by the authors, only 4 patients in the Toronto study had incomplete (R2) resections.
  • The authors stated that the patterns of recurrence were similar to those in earlier studies of extrapleural pneumonectomy with postoperative radiation.
  • The authors suggested, as a possibility, that preoperative radiation might be affecting immune response in some patients, and that this might influence survival.
• The authors' conclusion: The authors concluded that the results could be corroborated by using the approach at a few other centers with similar expertise. They also concluded that human and animal studies of how preoperative radiation interacts with immune response would likely be more productive than a randomized trial of uncertain feasibility.
• Limitations the authors state:
  • The authors stated that only high-volume centers of excellence could potentially reproduce the results.
  • The authors questioned whether the survival results reflected patient selection rather than the treatment itself.
  • The authors noted that current staging methods make it hard to predict accurately whether a tumor can be removed.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Mesothelioma, Pleural Mesothelioma, Intensity-Modulated Radiation Therapy (IMRT), Extrapleural Pneumonectomy (EPP), Median Overall Survival, Epithelioid, Staging, Pneumonitis.

Related studies

• Accelerated hemithoracic radiation followed by extrapleural pneumonectomy for malignant pleural mesothelioma — M. de Perrot, R. Feld, et al. (2016)
• Discussion — D. Rice, D. Sugarbaker, et al. (2016)
• A feasibility study evaluating Surgery for Mesothelioma After Radiation Therapy: the "SMART" approach for resectable malignant pleural mesothelioma — B.C. Cho, R. Feld, et al. (2014)
• Improved Outcomes with Modern Lung-Sparing Trimodality Therapy in Patients with Malignant Pleural Mesothelioma — F. Shaikh, M.G. Zauderer, et al. (2017)
• Mesothelioma at era of helical tomotherapy: results of two institutions in combining chemotherapy, surgery and radiotherapy — A. Sylvestre, M.A. Mahé, et al. (2011)
• Hemithoracic radiotherapy for mesothelioma: lack of benefit or lack of statistical power? — A. Rimner, C.B. Simone, et al. (2016)

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