Surgery in mesothelioma--where do we go after MARS?

Our plain-English summary of Surgery in mesothelioma--where do we go after MARS?, by B.I. Hiddinga, J.P. van Meerbeeck (Journal of Thoracic Oncology, 2013).

The study

• Authors: B.I. Hiddinga, J.P. van Meerbeeck
• Journal: Journal of Thoracic Oncology
• Published: 2013;8(5):525-9
• Type of article: Review
• Cited by: 27 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

The role of surgery in the management of malignant pleural mesothelioma remains controversial. Surgical resection consists of different procedures for diagnostic or therapeutic reasons. The latter includes either an extrapleural pleuropneumonectomy (EPP) or lung-sparing operations like debulking of the parietal and visceral pleura by pleurectomy/decortication (P/D) or extended pleurectomy/decortication, in which further debulking of the diaphragm or pericardium is included. Because of the modest outcome of surgery as single-modality therapy, combinations of chemotherapy, surgery, and radiation therapy were initiated as a new treatment strategy to improve prognosis. The observations that patients treated with P/D had an equal to better outcome than those treated with EPP, and that EPP with perioperative chemotherapy was better than EPP alone, raises the issue whether performing a P/D with perioperative chemotherapy would result in a further improvement of outcome with a lower operative mortality than with EPP and perioperative chemotherapy. This is the rationale for the next European Organisation for Research and Treatment of Cancer trial exploring the feasibility of P/D with perioperative chemotherapy.

In plain English

This was a concise review of published research on surgery for malignant pleural mesothelioma, written as background to a planned European Organisation for Research and Treatment of Cancer (EORTC) trial. It did not study asbestos exposure. The authors summarized studies of two main operations: extrapleural pleuropneumonectomy (EPP), which removes the pleura together with the lung on that side, and lung-sparing pleurectomy/decortication (P/D). In one systematic review they cited, median survival after EPP ranged from 9.4 to 27.5 months. In the MARS feasibility trial, only 50 of 112 registered patients were randomized, and patients allocated to no EPP had better median and 1-year survival than those given EPP. A pooled series of 663 patients from three U.S. centers found essentially no survival differences, stage by stage, between P/D (median survival 16 months) and EPP (12 months). The authors noted that retrospective series carry selection bias. They concluded that data on P/D combined with chemotherapy require prospective confirmation. They described a planned EORTC randomized phase 2 trial of P/D with chemotherapy given before or after surgery, needing 64 patients.

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: Concise (narrative) review of published studies, written as background to a planned EORTC randomized phase 2 trial
• Who was studied: Patients with malignant pleural mesothelioma in previously published surgical series, systematic reviews and trials (including the MARS trial); no new patients were studied
• Exposure: Not about asbestos exposure. The 'exposures' compared were treatments: extrapleural pleuropneumonectomy (removal of pleura with the lung, pericardium and diaphragm on that side) versus lung-sparing pleurectomy/decortication, alone or combined with chemotherapy and radiotherapy
• Main results:
  • In a cited systematic review of 34 series (2462 patients), median overall survival after EPP ranged from 9.4 to 27.5 months
  • In a cited systematic review of 1270 patients from 26 reports on lung-sparing surgery, operative mortality was 4%
  • In the MARS feasibility trial, 50 of 112 registered patients were randomized. Patients allocated to no EPP had better median and 1-year overall survival than those treated with EPP, and quality of life was worse in EPP-treated patients
  • A cited pooled series of 663 patients with stages I to IV disease from three U.S. centers showed essentially no survival differences, stage by stage, between P/D (median survival 16 months) and EPP (12 months). Operative mortality was 7% for EPP and 4% for P/D
  • In a cited prospective series of 36 patients, median overall survival was 23 months with extended P/D, reported as significantly better than 12.8 months with EPP
  • A cited retrospective analysis of an international database of 3101 patients showed no difference in median survival between EPP and P/D, except in stage I patients (40 months with EPP versus 23 months with P/D)
  • The planned EORTC randomized phase 2 trial will compare four cycles of cisplatin/pemetrexed chemotherapy before P/D with the same chemotherapy after P/D, and requires 64 patients (32 per arm)
• The authors' conclusion: The authors concluded that data on P/D as part of multimodality treatment come mostly from retrospective, selected series and require prospective confirmation. They hoped the planned trials would clarify the role of P/D before a phase 3 comparison of EPP and P/D.
• Limitations the authors state:
  • The authors noted selection bias in retrospective series, in which fitter patients receive more aggressive treatment and appear to do better
  • The authors noted that the MARS trial's sample size was too small for survival as a primary end point
  • The authors noted that extended P/D lacks standardization and uniformity

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, Surgical Resection, Visceral Pleura, Pleurectomy/Decortication (P/D), Diaphragm, Pericardium, Chemotherapy.

Related studies

• 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)
• Surgery for mesothelioma: MARS landing and future missions — T. Treasure (2010)
• Multimodal management of malignant pleural mesothelioma: where are we today? — P.E. Van Schil, I. Opitz, et al. (2014)
• SMART: logical radiotherapy and surgery beyond MARS — H.I. Pass (2021)
• Surgery as part of radical treatment for malignant pleural mesothelioma — D.A. Waller, S. Tenconi (2017)
• The use of surgery in mesothelioma — J.Y. Lim, A.S. Wolf, et al. (2013)

Browse more research in Journal of Thoracic Oncology, or return to medical research.