Surgery as part of radical treatment for malignant pleural mesothelioma

Our plain-English summary of Surgery as part of radical treatment for malignant pleural mesothelioma, by D.A. Waller, S. Tenconi (Current Opinion in Pulmonary Medicine, 2017).

The study

• Authors: D.A. Waller, S. Tenconi
• Journal: Current Opinion in Pulmonary Medicine
• Published: 2017;23(4):334-338
• Type of article: Review
• Cited by: 3 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Purpose Of Review: To review the latest developments in surgery for malignant pleural mesothelioma both in patient selection, surgical technique, and strategy.

Recent Findings: The International Association for the Study of Lung Cancer mesothelioma staging project has produced data to inform the 8th tumour node metastasis revision. The difficulty in clinical N staging and clinical T staging are highlighted and the importance of tumour volume is recognized. New imaging techniques can be utilized to assess tumour volume. The transition from extrapleural pneumonectomy to lung-sparing pleurectomy/decortication has extended the role of cancer-directed surgery into a more elderly population. More aggressive multimodality regimes, including induction radiotherapy are available to a selected population and adjuvant radiotherapy and chemotherapy are feasible in the elderly majority. Additional chemotherapy should not be delayed in those with poorer prognosis node positive, nonepithelioid disease.

Summary: Radical surgery for malignant pleural mesothelioma can achieve significant survival when targeted in those with the best prognosis by careful staging. It can be made more accessible by lung preservation without compromising outcome. It should be part of multimodality therapy.

In plain English

This article was a review by two authors at St Bartholomew's Hospital, London, of recent work on surgery for malignant pleural mesothelioma. It covered staging, patient selection, surgical technique and combined treatment, and did not discuss asbestos exposure. It described findings from an international staging project that drew on over 3000 cases, other studies' results on tumour volume and imaging, and the shift from extrapleural pneumonectomy (removal of the lung) to lung-sparing pleurectomy/decortication. Among the reported results: in one cited study of patients after pleurectomy/decortication, those whose tumours were 100% epithelioid had a median survival of 20.1 months, against 6.6 months for those with less than 50% epithelioid tumour. A cited Japanese trial using extrapleural pneumonectomy reported early mortality of almost 10%. The authors concluded that opinion is moving toward lung-sparing surgery, and that older patients need not be denied radical surgery, with caveats. They also concluded that the most intensive regimes should be kept for the fittest minority. They noted that most staging data came from surgical patients, although the disease is usually treated without surgery.

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 recently published studies on surgery for malignant pleural mesothelioma
• Who was studied: Patients with malignant pleural mesothelioma in the published studies reviewed, including an international staging project drawing on over 3000 cases from institutional databases worldwide
• Exposure: The review does not address asbestos exposure. It reviewed treatments: extrapleural pneumonectomy, lung-sparing pleurectomy/decortication, radiotherapy given before or after surgery, and chemotherapy
• Main results:
  • In the staging project's nodal analysis, nodal staging was simplified: all lymph node disease on the same side as the tumour is classified as pN1, and pN2 is used for spread to nodes on the opposite side of the chest
  • In the staging project, nodal staging by non-invasive (clinical) methods did not separate survival between the clinical nodal stages
  • For tumour (T) staging, the only recommendation for the 8th revision was to merge stages T1a and T1b into a single T1 category
  • In exploratory analyses of the staging data, tumour thickness and tumour shape (nodular or rind-like) were found to be prognostic factors
  • In a cited study of patients after pleurectomy/decortication, those with 100% epithelioid tumour had a median survival of 20.1 months, compared with 6.6 months for those with less than 50% epithelioid tumour
  • In the cited Japanese Mesothelioma Interest Group 0601 trial, which combined chemotherapy before surgery, extrapleural pneumonectomy and radiation after surgery, the regime was difficult to complete in more than 50% of patients, and early mortality was almost 10%
  • A cited study reported a 5-year survival rate of 14% after pleurectomy/decortication. The authors stated that survival was not compromised even though incomplete resection may be more common with this operation
  • In a cited nonrandomized study of patients with nonepithelioid disease, waiting to give chemotherapy until the disease progressed was linked to worse overall survival in patients with lymph node involvement (15.6 versus 8.2 months)
• The authors' conclusion: The authors concluded that international opinion is moving away from extrapleural pneumonectomy toward lung-sparing pleurectomy/decortication. They concluded that extremely radical regimes including extrapleural pneumonectomy should be reserved for the fittest minority, and that patients who avoid that operation are best treated with additional chemotherapy.
• Limitations the authors state:
  • Most of the staging project's data came from surgical patients, although the disease is usually treated without surgery
  • In the cited database study of older patients, the better survival seen with surgery may reflect which patients were chosen for surgery (selection bias)

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, Lung Cancer, Mesothelioma Staging, Metastasis, Staging, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D), Chemotherapy.

Related studies

• The management of the diaphragm during radical surgery for malignant pleural mesothelioma — A.J. Sharkey, R. Bilancia, et al. (2016)
• The new case for cervical mediastinoscopy in selection for radical surgery for malignant pleural mesothelioma — A. Nakas, D. Waller, et al. (2012)
• How does the timing of chemotherapy affect outcome following radical surgery for malignant pleural mesothelioma? — A.J. Sharkey, K.J. O'Byrne, et al. (2016)
• How successful is lung-preserving radical surgery in the mesothelioma and radical surgery-trial environment? A case-controlled analysis — Y. Shahin, J. Wellham, et al. (2011)
• Multimodal therapy of malignant pleural mesothelioma: is the replacement of radical surgery imminent? — J. Lindenmann, V. Matzi, et al. (2013)
• Extra-pleural pneumonectomy versus no extra-pleural pneumonectomy for patients with malignant pleural mesothelioma: clinical outcomes of the Mesothelioma and Radical Surgery (MARS) randomised feasibility study — T. Treasure, L. Lang-Lazdunski, et al. (2011)

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