Surgical treatment of malignant pleural mesothelioma

Our plain-English summary of Surgical treatment of malignant pleural mesothelioma, by A.J. Kaufman, R.M. Flores (Current Treatment Options in Oncology, 2011).

The study

• Authors: A.J. Kaufman, R.M. Flores
• Journal: Current Treatment Options in Oncology
• Published: 2011;12(2):201-16
• Cited by: 27 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Malignant Pleural Mesothelioma (MPM) remains a rare and lethal disease that is directly related to asbestos exposure in the vast majority of cases. While the total number of cases remains low compared to other malignancies, the worldwide incidence is expected to increase over the next twenty years. Currently, survival rates remain dismal and there is no standard therapy or consensus regarding treatment. However, over the last fifteen years there have been substantial improvements in the diagnosis and treatment of MPM, including easier and more accurate diagnostic techniques, improved methods of staging, more effective systemic therapy, a remarkable decrease in operative mortality, marked improvements in local control with adjuvant therapy, and perhaps most important, an emphasis on multidisciplinary care and multimodality clinical trials. Despite these advances, optimal therapy for these patients remains highly controversial and the role of surgery is actively debated. Most controversy centers on whether surgery increases survival and whether a survival benefit is best achieved with extrapleural pneumonectomy or pleurectomy/decortication within a multimodal regimen. To date, trimodality therapy that includes surgery, chemotherapy, and radiation offers the best survival advantage. It is generally accepted that the main goals of surgery, within the framework of a multimodality approach, is not only complete resection if possible, but more realistically, the resection of all macroscopic disease as an adjunct to the delivery of chemotherapy and radiation. The surgical options available to obtain this goal include extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). There are no randomized trials directly comparing EPP and P/D and the level of evidence supporting either technique remains low. Ultimately, the choice of operation depends on multiple factors including: disease stage, the patient's cardiopulmonary reserve, surgeon experience and philosophy, and the extent of planned adjuvant therapy. Yet, despite the inherent biases in most studies, the data thus far illustrates significant survival advantages with both P/D and EPP and surgeons should consider these approaches in select patients.

In plain English

This article was a narrative review of published research on surgery for malignant pleural mesothelioma. The authors described this cancer as directly related to asbestos exposure in the vast majority of cases. The article reported no new patient data. The authors reviewed studies of two operations: extrapleural pneumonectomy (EPP), and pleurectomy/decortication (P/D), which they called a lung sparing procedure. These operations were studied alone or combined with chemotherapy and radiation. The authors noted that no randomized trials directly compared EPP and P/D. They also noted that the lack of control groups introduced selection bias in nearly all studies. Among the studies they described, a multicenter review reported median survival of 16 months after P/D and 12 months after EPP. A multicenter trial of chemotherapy, EPP and radiation reported median survival of 16.8 months for all patients analyzed and 29 months for those who completed all three treatments. The authors concluded that the evidence supported aggressive treatment with surgery and trimodality therapy, using either EPP or P/D, in carefully selected patients at experienced centers. They said a randomized trial was needed to prove that surgery helps.

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 literature review / opinion article; no new patient data
• Who was studied: Published studies of patients with malignant pleural mesothelioma treated with or without surgery. The summary tables list studies with study periods from 1959 to 2007.
• Exposure: Not an exposure study. The review is about treatments: extrapleural pneumonectomy and pleurectomy/decortication, with or without chemotherapy and radiation. Asbestos is mentioned only as the cause in most cases, and no fiber types are discussed.
• Main results:
  • The authors described P/D as a lung sparing procedure, in contrast to EPP.
  • The authors reported that no randomized trials directly compared EPP and P/D, and that the level of evidence for either technique was low.
  • In a cited multicenter retrospective review (Flores and colleagues), median survival of all patients was 14 months: 16 months after P/D and 12 months after EPP.
  • In a cited multicenter phase II trial (Krug and colleagues) of chemotherapy before EPP and radiation, median survival was 16.8 months for the intent-to-treat group and 29 months for those who completed all three treatments.
  • In a cited Toronto study (de Perrot et al), median survival on intent-to-treat analysis was 14 months. The review's authors took this to suggest that trimodality therapy benefits only a select group of patients.
  • In a cited SEER database analysis (Flores and colleagues), only 22% of 5937 patients underwent cancer-directed surgery.
  • In a cited Brigham and Women's Hospital series (Sugarbaker and colleagues), the 176 patients who survived 30 days after EPP had a median survival of 19 months, with 2-year and 5-year survival of 38% and 15%.
• The authors' conclusion: The authors concluded that recent data support aggressive treatment with surgery and trimodality therapy, using either EPP or P/D, in carefully selected patients at experienced centers. They said a randomized controlled trial is needed to prove surgical benefit.
• Limitations the authors state:
  • The authors stated that the lack of control groups introduces selection bias in nearly all of the studies reviewed.
  • The authors stated that studies combined many different additional therapies, which makes comparisons between studies difficult.
  • The authors stated that a randomized controlled trial is needed to prove surgical benefit.

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, Asbestos Exposure, Staging, Systemic Therapy, Adjuvant Therapy, Multidisciplinary Team, Clinical Trial, Extrapleural Pneumonectomy (EPP).

Related studies

• A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma — C. Cao, D. Tian, et al. (2014)
• The importance of surgical staging in the treatment of malignant pleural mesothelioma — V.W. Rusch, E. Venkatraman (1996)
• Treatment of malignant pleural mesothelioma with chemotherapy preceding versus after surgical resection — V. Verma, C.A. Ahern, et al. (2019)
• Solitary fibrous tumors of the pleura: clinical characteristics, surgical treatment and outcome — P. Magdeleinat, M. Alifano, et al. (2002)
• The role of surgical cytoreduction in the treatment of malignant pleural mesothelioma: meeting summary of the International Mesothelioma Interest Group Congress, September 11-14, 2012, Boston, Mass — V. Rusch, E.H. Baldini, et al. (2013)
• Photodynamic therapy and the evolution of a lung-sparing surgical treatment for mesothelioma — J.S. Friedberg, R. Mick, et al. (2011)

Browse more research in Current Treatment Options in Oncology, or return to medical research.