Surgical management of malignant pleural mesothelioma

Our plain-English summary of Surgical management of malignant pleural mesothelioma, by J. Yanagawa, V. Rusch (Thoracic Surgery Clinics, 2013).

The study

• Authors: J. Yanagawa, V. Rusch
• Journal: Thoracic Surgery Clinics
• Published: 2013;23(1):73-87, vi
• Type of article: Review
• Cited by: 8 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

The uniquely diffuse nature of malignant pleural mesothelioma (MPM) makes it difficult to diagnose, stage, and treat. In addition, it is a relatively uncommon disease, making adequate prospective trials difficult to perform and leading to several controversies regarding the best management of MPM. Perhaps the greatest area of dispute is whether extrapleural pneumonectomy or pleurectomy/decortication is the most appropriate curative operation for patients who are physiologically candidates for both. Although median survival remains poor, important strides have been made in the treatment of MPM, mainly in the form of multimodality therapeutic regimens.

Copyright © 2013 Elsevier Inc. All rights reserved.

In plain English

This article was a review, not a new study. The authors, surgeons at Memorial Sloan-Kettering Cancer Center in New York, summarized published research and their center's practice on surgery for malignant pleural mesothelioma, a cancer of the lining around the lungs that the article links to asbestos exposure. They covered diagnosis, staging, chemotherapy, radiation, and the two main operations. Extrapleural pneumonectomy (EPP) removes the lung along with the pleura. Pleurectomy/decortication (P/D) leaves the lung in place. Citing other studies, they reported death rates from surgery of 4% to 15% for EPP and 1% to 5% for P/D. A cited study of 663 patients found shorter median survival after EPP than after P/D (12 vs 16 months), which the authors said was likely related to selection bias. They stated that combining surgery, radiation and chemotherapy gave the best results, though median survival was still poor (17 to 30 months). The authors noted that no randomized studies show surgery improves survival. They concluded that the choice of operation should weigh complete tumor removal, available follow-up treatments and prognostic factors.

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 surgical management of malignant pleural mesothelioma, including a description of the authors' institution's surgical technique and care; no new data collected
• Who was studied: No study population of its own; the review drew on published studies of patients with malignant pleural mesothelioma and on practice at Memorial Sloan-Kettering Cancer Center (MSKCC), New York
• Exposure: Asbestos exposure appeared only as background, as the known association with malignant pleural mesothelioma. No fiber types were named. Citing CDC/NIOSH data on mesothelioma deaths in 1999, the article listed associated industries (for example ship and boat building and repair, construction) and occupations (for example plumbers, pipefitters, steamfitters, electricians). The review itself was about treatment, not exposure.
• Main results:
  • The authors stated that multimodality therapy (surgery, radiation therapy and chemotherapy) gives the best results in malignant pleural mesothelioma, although median survival is still poor (17 to 30 months)
  • Citing another study: mortality from the operation ranges from 4% to 15% for EPP and from 1% to 5% for P/D, and morbidity (complications) is 23% for EPP compared with 10.5% for P/D
  • Citing a retrospective review (Flores and colleagues, 2008) of 663 patients operated on at 3 institutions between 1990 and 2006: operative mortality was 7% for EPP and 4% for P/D. Median survival was 12 months after EPP vs 16 months after P/D. The review authors said this was likely related to selection bias, because the two groups differed in age, stage and therapy received.
  • Citing the same comparison: local recurrence was 33% after EPP vs 65% after P/D
  • Citing the MARS randomized feasibility study (Treasure and colleagues): 50 patients were assigned to EPP (24) or no EPP (26). Median survival was 19.5 months for the no-EPP group vs 14.4 months for the EPP group. There were too few patients for definitive conclusions, and operative mortality in this trial was 18%.
  • Citing a randomized phase III trial (Vogelzang and colleagues, 2003) of 448 patients with unresectable malignant pleural mesothelioma: median survival was 12.1 months with cisplatin plus pemetrexed vs 9.3 months with cisplatin alone
  • Citing an MSKCC phase II trial of 54 patients who had EPP followed by high-dose (54 Gy) radiation to one side of the chest: local recurrence was 13% and median survival among patients with early-stage disease was 33.8 months
  • Citing a multicenter phase II trial of 77 patients given chemotherapy (pemetrexed plus cisplatin), then EPP, then radiation: median survival was 16.8 months for all patients enrolled (intention-to-treat), 21.9 months for those who had EPP (74%), and 29.1 months for those who completed all 3 therapies (52%)
• The authors' conclusion: The authors concluded that, without strong evidence-based guidelines, the choice between EPP and P/D should take into account whether complete resection can be achieved, the available adjuvant therapies and prognostic factors. They also stated that patients should be cared for at centers with multidisciplinary expertise.
• Limitations the authors state:
  • The authors stated that the benefit of surgery remains largely assumed, because no randomized studies have shown that surgery improves survival
  • The authors stated that the two operations are chosen in different clinical situations, which makes it difficult to compare their outcomes directly in retrospective studies

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, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D), Median Survival.

Related studies

• Surgical Management of Malignant Pleural Mesothelioma: An Update of Clinical Evidence — C. Cao, Z. Akhunji, et al. (2015)
• Should we continue to offer extrapleural pneumonectomy to selected mesothelioma patients? A single center experience comparing surgical and non-surgical management — M. Baud, A. Bobbio, et al. (2014)
• Three decades of experience in the surgical multi-modality management of pleural mesothelioma — H. Luckraz, M. Rahman, et al. (2010)
• Current surgical strategies for malignant pleural mesothelioma — T. Takuwa, S. Hasegawa (2016)
• Multimodal management of malignant pleural mesothelioma: where are we today? — P.E. Van Schil, I. Opitz, et al. (2014)
• Cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion for malignant pleural tumours: perioperative management and clinical experience — M. Ried, T. Potzger, et al. (2013)

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