Survival after trimodality therapy for malignant pleural mesothelioma: Radical Pleurectomy, chemotherapy with Cisplatin/Pemetrexed and radiotherapy

Our plain-English summary of Survival after trimodality therapy for malignant pleural mesothelioma: Radical Pleurectomy, chemotherapy with Cisplatin/Pemetrexed and radiotherapy, by S. Bölükbas, C. Manegold, M. Eberlein, et al (Lung Cancer, 2011).

The study

• Authors: S. Bölükbas, C. Manegold, M. Eberlein, T. Bergmann, A. Fisseler-Eckhoff, J. Schirren
• Journal: Lung Cancer
• Published: 2011;71(1):75-81
• Cited by: 109 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: The role of surgery in the management of malignant pleural mesothelioma (MPM) is controversial and there are no established guidelines. We describe the feasibility and long-term outcomes associated with Radical Pleurectomy (RP) as surgical therapy modality in a standardized trimodality therapy concept of MPM.

Methods: From November 2002 to October 2007, 35 out of 102 consecutive patients with MPM were enrolled in our prospective database. They underwent trimodality therapy, including RP followed by 4 cycles of chemotherapy with Cisplatin (75 mg/m(2))/Pemetrexed (500 mg/m(2)) and radiotherapy 4-6 weeks after operation.

Results: Median age was 65 years. Nineteen patients were in advanced stages III and IV (54.3%). Tumor histology was epithelial in 27 patients (77.1%). Macroscopic complete resection could be achieved in 18 patients (51.4%). Surgical morbidity/mortality and trimodality treatment-related mortality were 20.0%, 2.9% and 5.8%, respectively. Thirty-three patients completed the trimodality therapy. Median follow-up was 21.7 months. Overall median survival was 30.0 months. One-, 2-, and 3-year-survival were 69%, 50% and 31%, respectively. Advanced stages III/IV (p=0.06), macroscopic incomplete resections (p=0.001), non-epithelial histology (p=0.55) and nodal metastases (p=0.19) were associated with poorer survival.

Conclusions: The trimodality therapy concept with RP demonstrates promising results in terms of long-term survival, morbidity and mortality. We propose that a surgical philosophy of limiting the procedure related morbidity while achieving comparable cytoreductive results allows patients to maintain physiological reserve to be eligible for multimodality treatment options in the long-term. The observed and theoretical benefits of this trimodality treatment approach warrant confirmation in larger RCT.

Copyright © 2009 Elsevier Ireland Ltd. All rights reserved.

In plain English

This German study followed patients with malignant pleural mesothelioma treated with radical pleurectomy (surgery removing the pleura but keeping the lung), four cycles of cisplatin/pemetrexed chemotherapy, and radiotherapy. Of 102 consecutive patients seen from November 2002 to October 2007, 35 were treated and 33 completed all three treatments. Asbestos exposure was not discussed. Visible tumor was completely removed in 18 patients (51.4%). Surgical complications occurred in 20.0% of patients, surgical deaths in 2.9%, and deaths from any part of treatment in 5.8%. Overall median survival was 30.0 months (95% confidence interval 20.0 to 39.9), with 69%, 50% and 31% alive at one, two and three years. Mean survival was 43.3 months (95% confidence interval 27.9 to 58.7) when visible tumor was fully removed and 14.0 months (8.3 to 19.6) when it was not (p = 0.001). Differences by stage, tumor type and lymph node spread were not statistically significant. Local recurrence occurred in 12 of 33 patients. The authors called the results promising, noted the small numbers and possible patient selection, and called for larger controlled studies.

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: Prospective single-center pilot study of one treatment approach, with no comparison group
• Who was studied: 35 of 102 consecutive patients with histologically diagnosed malignant pleural mesothelioma, enrolled November 2002 to October 2007 at a thoracic surgery department in Wiesbaden, Germany. Mean age was 65.0 years and 29 were male.
• Exposure: Asbestos exposure was not reported. The study examined a treatment: radical pleurectomy followed by four cycles of cisplatin (75 mg/m2) and pemetrexed (500 mg/m2) chemotherapy, and radiotherapy starting 4 to 6 weeks after surgery.
• Main results:
  • Overall median survival for the 35 patients was 30.0 months (95% CI 20.0 to 39.9). One-, 2- and 3-year survival were 69%, 50% and 31%.
  • Surgical morbidity was 20.0% and surgical mortality was 2.9%. Treatment-related mortality of any cause was 5.8%. 33 patients completed the trimodality therapy.
  • Macroscopic complete resection was achieved in 18 of 35 patients (51.4%).
  • Mean survival was 43.3 months (95% CI 27.9 to 58.7) after macroscopically complete resection (n = 18) and 14.0 months (95% CI 8.3 to 19.6) after incomplete resection (n = 17), p = 0.001.
  • Advanced stage (p = 0.06), non-epithelial histology (p = 0.55) and nodal metastases (p = 0.19) were reported as associated with poorer survival. The authors set statistical significance at p less than 0.05, so none of these three reached it.
  • In a subgroup of 8 patients (stage I, epithelial histology, macroscopic complete resection, initially eligible for extrapleural pneumonectomy), median survival was 56.4 months (95% CI 33.0 to 79.8).
  • Among the 33 treated patients, progression-free survival was 15.8 months. Local recurrence occurred in 12 of 33 (36.4%) and distant metastases in 8 (24.2%). The authors described local control as unacceptable.
• The authors' conclusion: The authors concluded that trimodality therapy with radical pleurectomy showed promising results for treatment-related morbidity, mortality and long-term survival, and was feasible in all stages. They said its benefits warrant confirmation in larger multi-center prospective controlled studies.
• Limitations the authors state:
  • The number of patients was small, so the differences found could be due to chance.
  • The high survival rates could be attributed to patient selection, and survival might be affected by undefined tumor biological factors and non-surgical treatments.
  • The study cannot determine the influence of each individual treatment on outcome.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Trimodality Therapy, Pleural Mesothelioma, Chemotherapy, Cisplatin, Pemetrexed (Alimta), Histology, Median Survival, Cytoreductive Surgery.

Related studies

• Trimodality strategy for treating malignant pleural mesothelioma: results of a feasibility study of induction pemetrexed plus cisplatin followed by extrapleural pneumonectomy and postoperative hemithoracic radiation (Japan Mesothelioma Interest Group 0601 Trial) — S. Hasegawa, M. Okada, et al. (2016)
• A feasibility study of induction pemetrexed plus cisplatin followed by pleurectomy/decortication aimed at macroscopic complete resection for malignant pleural mesothelioma — M. Shimokawa, S. Hasegawa, et al. (2013)
• Long progression-free survival by pemetrexed continuation maintenance therapy following cisplatin-based chemotherapy in malignant pleural mesothelioma — T. Takeda, H. Itano, et al. (2014)
• A Phase II Trial of First-Line Combination Chemotherapy With Cisplatin, Pemetrexed, and Nivolumab for Unresectable Malignant Pleural Mesothelioma: A Study Protocol — N. Fujimoto, K. Aoe, et al. (2018)
• Systemic chemotherapy with pemetrexed and cisplatin for malignant peritoneal mesothelioma: a single institution experience — G. Lainakis, F. Zagouri, et al. (2011)
• Trimodality therapy for malignant pleural mesothelioma: results from an EORTC phase II multicentre trial — P.E. Van Schil, P. Baas, et al. (2010)

Browse more research in Lung Cancer, or return to medical research.