Taken Together: Effective Multimodal Approaches for Malignant Pleural Mesothelioma

Our plain-English summary of Taken Together: Effective Multimodal Approaches for Malignant Pleural Mesothelioma, by K.J. Song, R.M. Flores, A.S. Wolf (Thoracic Surgery Clinics, 2020).

The study

• Authors: K.J. Song, R.M. Flores, A.S. Wolf
• Journal: Thoracic Surgery Clinics
• Published: 2020;30(4):481-487
• Type of article: Review
• Cited by: 9 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Malignant pleural mesothelioma is an aggressive, deadly cancer often requiring input from multiple medical disciplines. Treatment has evolved over the last several decades with increasing evidence and ongoing advances in chemotherapy, radiation, and immunotherapy; however, no standard treatment regimen has yet been defined. Regardless of the overall strategy, surgery remains the foundation of treatment to remove macroscopic disease, and preservation of lung parenchyma via extended pleurectomy/decortication may be preferable to extrapleural pneumonectomy.

Copyright © 2020 Elsevier Inc. All rights reserved.

In plain English

This article was a narrative review of treatments for malignant pleural mesothelioma. It reported no new patient data and did not discuss asbestos exposure. The authors described surgery, chemotherapy, radiation and immunotherapy, and summarized results from other published studies. The two main operations are extrapleural pneumonectomy, which removes the lung, and extended pleurectomy/decortication, which spares it. Among the studies they cited, these operations carried mortality rates of 2.2% to 7.0%. A meta-analysis from the authors' institution, covering 659 patients, found that quality of life was reduced for at least 6 months after either operation and was worse after pneumonectomy. One cited immunotherapy study gave pembrolizumab to 25 patients who had failed or could not receive standard therapy, and 20% of them had a partial response. The authors wrote that no standard treatment has been defined, that surgery remains the cornerstone of combined therapy, and that their own practice is to choose pleurectomy/decortication whenever possible. They noted that recommendations are limited by a lack of randomized controlled trials and that most quality-of-life data come from small, single-center observational 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: Narrative review of published studies on multimodal treatment of malignant pleural mesothelioma. It has no methods section and presents no original data.
• Who was studied: Patients with malignant pleural mesothelioma, as described in the published studies the authors reviewed. The authors are from the Department of Thoracic Surgery, Mount Sinai Health System, New York.
• Exposure: Not an exposure study; asbestos is not discussed. The treatments reviewed were surgery (extrapleural pneumonectomy and extended pleurectomy/decortication), systemic chemotherapy (mainly cisplatin/pemetrexed), hyperthermic intraoperative chemotherapy, immunotherapy, and radiation therapy.
• Main results:
  • Cited studies: both main operations (extrapleural pneumonectomy and pleurectomy/decortication) carried a mortality rate of 2.2% to 7.0%.
  • A cited series of 183 patients who had extrapleural pneumonectomy with adjuvant chemotherapy and radiation: mortality was 3.8%, morbidity was 50%, and median survival was 19 months for those surviving the perioperative period.
  • A cited meta-analysis from the authors' institution, covering 659 patients: quality of life was diminished after either surgery for at least 6 months and was worse for extrapleural pneumonectomy patients on both physical and social measures.
  • In the Surveillance, Epidemiology, and End Results dataset from 1990 to 2004, only 22% of patients with malignant pleural mesothelioma received cancer-directed surgery.
  • A cited phase IB study of pembrolizumab in 25 patients who had failed or could not receive standard therapy: 20% had a partial response and 52% had stable disease.
  • The cited DETERMINE randomized trial of tremelimumab in unresectable pleural or peritoneal mesothelioma found no difference in survival between the treatment and placebo groups.
  • Cited follow-up of the SMART approach (radiation before extrapleural pneumonectomy) in 62 patients: 1.6% perioperative mortality, 4.8% treatment-related mortality, and median survival of 36 months on an intention-to-treat basis. Median overall survival was 51 months in epithelioid subtypes versus 10 months in biphasic subtypes.
• The authors' conclusion: The authors concluded that no single approach constitutes effective treatment and that quality of life should be prioritized. In their view, surgery remains a critical part of treatment, and debulking by pleurectomy/decortication is growing in favor over extrapleural pneumonectomy. Their own practice is to opt for pleurectomy/decortication whenever possible.
• Limitations the authors state:
  • The authors stated that current recommendations are limited by the lack of quality data from randomized controlled trials.
  • The authors stated that most data on quality of life after either operation come from small, single-center, observational studies.
  • The authors stated that information from the national cancer databases they cited is inherently heterogeneous.

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, Chemotherapy, Immunotherapy, Parenchyma, Pleurectomy/Decortication (P/D), Extrapleural Pneumonectomy (EPP).

Related studies

• Multimodal management of malignant pleural mesothelioma: where are we today? — P.E. Van Schil, I. Opitz, et al. (2014)
• How does the timing of chemotherapy affect outcome following radical surgery for malignant pleural mesothelioma? — A.J. Sharkey, K.J. O'Byrne, et al. (2016)
• Multimodal therapy of malignant pleural mesothelioma: is the replacement of radical surgery imminent? — J. Lindenmann, V. Matzi, et al. (2013)
• Surgery as part of radical treatment for malignant pleural mesothelioma — D.A. Waller, S. Tenconi (2017)
• Extended Pleurectomy and Decortication for Malignant Pleural Mesothelioma Is an Effective and Safe Cytoreductive Surgery in the Elderly — T. Williams, H. Duraid, et al. (2015)
• Improved Outcomes with Modern Lung-Sparing Trimodality Therapy in Patients with Malignant Pleural Mesothelioma — F. Shaikh, M.G. Zauderer, et al. (2017)

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