Survival results in biphasic malignant pleural mesothelioma patients: A multicentric analysis

Our plain-English summary of Survival results in biphasic malignant pleural mesothelioma patients: A multicentric analysis, by F. Lococo, F. Torricelli, L. Lang-Lazdunski, et al (The Journal of Thoracic and Cardiovascular Surgery, 2020).

The study

• Authors: F. Lococo, F. Torricelli, L. Lang-Lazdunski, G. Veronesi, O. Rena, M. Paci, C. Casadio, S. Piana, P. Novellis, T.S. Di Stefano, A. Ciarrocchi, A. Billè
• Journal: The Journal of Thoracic and Cardiovascular Surgery
• Published: 2020;159(4):1584-1593.e2
• Cited by: 19 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objective: The best strategy of care for biphasic malignant pleural mesothelioma (Biph-MPM) is controversial. In this study, a large dataset of Biph-MPM cases was reviewed to identify prognostic factors and to evaluate the role of a multimodal approach, including cancer-directed surgery.

Methods: A total of 213 patients with Biph-MPM treated at 4 tertiary centers who experienced MPM from January 2009 to December 2016 were selected, and clinical, pathologic, and surgical information was retrieved. A Cox regression model was used to identify predictors of survival, and the Kaplan-Meier method was used to summarize overall survival.

Results: The mean age and the male/female ratio were 68.4 ± 9.5 years and 5:1, respectively. Tumors were assigned to stages I (127, 59.6%), II (3, 1.4%), III (76, 35.4%), and IV (7, 3.3%) according to the Eighth Tumor, Node, Metastasis (TNM) edition. A multimodal treatment including pleurectomy/decortication was performed in 58 patients (27.2%), chemotherapy alone in 99 patients (46.5%), and best supportive care in 56 (26.3%). The median overall survival was 11 months. A univariate analysis revealed that survival was significantly associated with the percentage forced expiratory volume in 1 second (P < .0001), performance status (P = .0002), multimodal treatment including surgery (P < .0001), and TNM stage (P = .011). A multivariable analysis confirmed performance status, percentage forced expiratory volume in 1 second, TNM, and a multimodal approach as independent variables affecting long-term survival.

Conclusions: Despite the overall poor prognosis of biphasic histology, a multimodal approach, including cancer-directed surgery, is associated with improved long-term results in very selected patients with Biph-MPM.

Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.

In plain English

This was a retrospective study of 213 patients with biphasic malignant pleural mesothelioma, a cancer of the lining of the lung whose tumor contains both epithelioid and sarcomatoid cells. They were diagnosed and treated from September 2009 to December 2016 at four specialist centers in Italy and the United Kingdom. The article does not discuss asbestos exposure. It compares treatments: cancer-directed surgery (pleurectomy/decortication), alone or with chemotherapy, in 58 patients (8 had surgery alone), chemotherapy alone in 99, and best supportive care in 56. Median survival was 11 months for the whole group. It was 17 months with surgery-based treatment, 13 months with chemotherapy alone and 5 months with supportive care only. In combined analysis, better performance status, better lung function, lower stage and surgery-based treatment were each linked to longer survival. The authors noted that patients chosen for surgery were younger and fitter, that the study had no control group, and that staging may have differed between groups. The authors concluded that surgery-based treatment seems a reasonable option for selected patients and that these patients should be included in future clinical trials.

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: Retrospective multi-institutional review of patient records (observational)
• Who was studied: 213 patients with biphasic malignant pleural mesothelioma (174 men, 39 women) diagnosed and treated from September 2009 to December 2016 at 4 tertiary centers in Reggio Emilia, Milan and Novara (Italy) and London (United Kingdom); patients who had extrapleural pneumonectomy were excluded
• Exposure: The article does not report asbestos exposure. The comparison is between treatments: a multimodal approach including cancer-directed surgery (pleurectomy/decortication) with or without (neo)adjuvant chemotherapy (58 patients, 8 of whom had surgery as their only treatment), chemotherapy alone (99), and best supportive care (56)
• Main results:
  • In the whole study population, median overall survival was 11 months, 1-year survival was 43% and 3-year survival was 5%
  • Median survival was 17 months for patients whose treatment included cancer-directed surgery
  • Median survival was 13 months for patients given chemotherapy alone and 5 months for patients given best supportive care only
  • In the multivariable analysis of all 213 patients, treatment including surgery was associated with longer survival (hazard ratio 0.55; 95% CI 0.35-0.86; P = .009). Better lung function (FEV1 above 80%: HR 0.31; 95% CI 0.22-0.45), performance status (HR 1.38; 95% CI 1.04-1.83) and stage I versus stages II-IV (HR 1.70; 95% CI 1.21-2.39) were also independent factors
  • Stage I patients: median survival was 20 months with surgery-based treatment and 10 months with chemotherapy only (HR 0.32; 95% CI 0.19-0.53)
  • Stage II to III patients: median survival was 16 months with surgery-based treatment and 7 months with chemotherapy only (HR 0.38; 95% CI 0.22-0.65)
  • Within the 58 surgical patients, preserved lung function (FEV1 above 80%) predicted better outcome (HR 0.33; 95% CI 0.13-0.86). Complete removal of visible tumor and (neo)adjuvant therapy did not significantly affect survival
  • The percentage of epithelioid cells in the tumor was not associated with survival
• The authors' conclusion: The authors concluded that, despite the poor prognosis of biphasic histology, a multimodal approach seems a reasonable option in selected cases at experienced centers. Because the study's limitations make the effect of surgery hard to demonstrate, they advocated including these patients in future clinical trials of multimodal treatment.
• Limitations the authors state:
  • Retrospective design, with clinical data missing for a small part of the sample
  • The comparison between surgical and nonsurgical patients may have been biased by differences in age, fitness or stage at presentation
  • Stage may have been underestimated in nonsurgical patients, which could have affected the survival comparisons
  • With no control group, patients selected for surgery may have done better even without surgery
  • No proper comorbidity index was included in the analysis
  • The comparison of poor survivors and long survivors was purely observational
  • Too few patients (8) had surgery alone to show the effect of (neo)adjuvant chemotherapy

Topics

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

Medical terms in this study, explained in our Lexicon: Biphasic Mesothelioma, Pleural Mesothelioma, Overall Survival, Metastasis, Pleurectomy/Decortication (P/D), Chemotherapy, Median Overall Survival, Performance Status.

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• Is Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Justified for Biphasic Variants of Peritoneal Mesothelioma? Outcomes from the Peritoneal Surface Oncology Group International Registry — K.I. Votanopoulos, P. Sugarbaker, et al. (2018)
• Is There a Role for Cancer-Directed Surgery in Early-Stage Sarcomatoid or Biphasic Mesothelioma? — S. Kim, D.A. Bull, et al. (2019)
• Does surgery improve survival of patients with malignant pleural mesothelioma?: a multicenter retrospective analysis of 1365 consecutive patients — P. Bovolato, C. Casadio, et al. (2014)
• What is the optimum strategy for thromboembolic prophylaxis following extrapleural pneumonectomy in patients with malignant pleural mesothelioma? — A. Billè, L. Okiror, et al. (2012)

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