Surgery for malignant pleural mesothelioma: why, when and what?

Our plain-English summary of Surgery for malignant pleural mesothelioma: why, when and what?, by L. Lang-Lazdunski (Lung Cancer, 2014).

The study

• Author: L. Lang-Lazdunski
• Journal: Lung Cancer
• Published: 2014;84(2):103-9
• Type of article: Review
• Cited by: 18 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Malignant pleural mesothelioma is a fatal cancer developing in the pleural cavity, linked to asbestos exposure. Various therapies have been tried in the past 50 years including surgery, radiotherapy, chemotherapy, immunotherapy and more recently, targeted therapy. Radical surgery remains controversial in malignant pleural mesothelioma and two procedures have been offered in the past to obtain maximal cytoreduction: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). Despite growing evidence that EPP might be detrimental, many believe that radical surgery should still be part of multimodality therapy in patients with malignant pleural mesothelioma. Recent evidence suggests that P/D is well tolerated and produces low mortality and morbidity. The role of adjuvant intrapleural therapies remains to be determined and evaluated in large prospective trials. Pleurectomy/decortication does not jeopardize the chance of having chemotherapy, or chemoradiotherapy either. Many now believe that it should be the default procedure in multimodality regimens. However, this remains to be proven in a large randomized trial. Palliative surgery still has an important role to play in mesothelioma, in establishing or refining diagnosis and in controlling symptoms and improving quality of life in many patients whose life expectancy is limited. Recent progress in molecular analyses and biomarkers should help with patient selection for surgery, immunotherapy and systemic therapies in the near future.

Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

In plain English

This was a narrative review of surgery for malignant pleural mesothelioma, which the article links to asbestos exposure. Asbestos exposure itself was not studied. The author reviewed reports on two radical operations and on palliative procedures. The operations were extrapleural pneumonectomy (EPP), which removes the lung on the operated side with its pleura, diaphragm and pericardium, and pleurectomy/decortication (P/D), which removes the pleura and, in radical or extended forms, also the diaphragm, pericardium or other structures. A cited systematic review by Cao et al. of 34 series (2462 patients) reported median survival after EPP of 9.4 to 27.5 months. Teh et al.'s systematic review of 1270 patients after lung-sparing surgery reported 4% operative mortality. The author wrote that it was hard to say which operation was better, and that survival differences may reflect selection bias. In the author's own experience, none of more than 100 patients given total P/D with prophylactic radiotherapy (the Boutin regimen) developed chest wall implants. The author concluded that radical surgery should remain part of multimodality therapy. The author added that whether P/D should be the default procedure remained to be proven in a large randomized trial.

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 on surgery for malignant pleural mesothelioma, with some remarks from the author's own surgical experience
• Who was studied: No new patient group. The article reviewed published surgical series and trials in patients with malignant pleural mesothelioma, including selected series summarized in two tables. It also briefly mentioned the author's own patients at Guy's Hospital, London.
• Exposure: Asbestos exposure was not studied. The article notes that the disease is linked to asbestos and focuses on surgical treatments (EPP, P/D, palliative procedures). No fiber types are named.
• Main results:
  • The article describes EPP as removal of the whole lung on the operated side together with the surrounding pleura, the same-side half of the diaphragm and the same-side pericardium.
  • The article cites proposed definitions for the pleurectomy procedures. Total pleurectomy removes all pleural tissues. Radical or extended pleurectomy also removes the diaphragm, pericardium or other structures.
  • The author cited a systematic review by Cao et al. of 34 series (2462 patients from 26 institutions). It reported median overall survival after EPP ranging from 9.4 to 27.5 months.
  • The author cited a systematic review by Teh et al. of 1270 patients from 26 reports on lung-sparing surgery. It reported an operative mortality of 4%, with survival rates of 26% at 2 years and 9% at 5 years.
  • The author described the MARS pilot study (50 randomized patients) as not powered to show that one treatment was superior. It showed 18 percent mortality in the EPP group and better survival in the no-EPP group.
  • The author wrote that recent evidence suggests P/D is well tolerated, with low mortality and morbidity.
  • The author's assessment was that it is currently difficult to say whether EPP or P/D is the better operation.
  • The author cited the UK National Lung Cancer Audit of 8503 pleural mesothelioma cases. Median survival was 388 days for epithelioid, 274 days for biphasic and 123 days for sarcomatoid histology.
  • The author cited the MESOVATS trial (VATS pleurectomy versus talc pleurodesis). No survival benefit was shown for VATS pleurectomy, but quality of life was significantly better at 6 and 12 months in that group. Complications were more common with VATS pleurectomy (26% versus 8%).
  • In the author's personal experience, no chest wall implants occurred in more than 100 patients who had total P/D at Guy's Hospital over 10 years. These patients also received prophylactic radiotherapy using the Boutin regimen.
  • In the author's personal experience, 98% of patients received 4 to 6 cycles of pemetrexed and cisplatin starting 6 to 8 weeks after radical P/D.
• The authors' conclusion: The author concluded that, despite growing evidence that EPP might be detrimental, radical surgery should still be part of multimodality therapy for malignant pleural mesothelioma.
• Limitations the authors state:
  • The author stated that whether P/D should be the default procedure in multimodality regimens remains to be proven in a large randomized trial.
  • The author stated that observed differences in survival between the operations may be due to selection bias.
  • The author stated that quality-of-life data after EPP are scarce.

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, Pleural Cavity, Asbestos Exposure, Chemotherapy, Immunotherapy, Targeted Therapy, Cytoreductive Surgery, Extrapleural Pneumonectomy (EPP).

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