The role of thoracic surgery in the management of mesothelioma: an expert opinion on the limited evidence

Our plain-English summary of The role of thoracic surgery in the management of mesothelioma: an expert opinion on the limited evidence, by P. Bertoglio, D.A. Waller (Expert Review of Respiratory Medicine, 2016).

The study

• Authors: P. Bertoglio, D.A. Waller
• Journal: Expert Review of Respiratory Medicine
• Published: 2016;10(6):663-72
• Type of article: Review
• Cited by: 20 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Surgery has a key role at different points in the management of Malignant Pleural Mesothelioma. Diagnosis with video assisted thoracoscopy offers excellent sensitivity and specificity and a direct view of the pleural cavity to verify the extent of the tumor. Nodal involvement can be assessed by mediastinoscopy and either talc pleurodesis or partial pleurectomy can be used for symptom control in advanced stage disease. Extra Pleural Pneumonectomy (EPP) and Extended Pleurectomy Decortication (EPD) are used to prolong survival although the benefit of radical surgery has not has been fully clarified; EPP failed to show its benefit in the MARS trial and EPD is currently under investigation in the MARS2 trial. More randomized prospective trial data are needed to fully understand the role of radical surgery in the treatment of pleural mesothelioma.

In plain English

This article is a narrative review and expert opinion on surgery for malignant pleural mesothelioma. The authors stated that a systematic review was not possible for lack of high-grade evidence. They searched PubMed for recent English-language publications. They wrote that there was compelling evidence for using video-assisted thoracoscopic surgery (VATS) for diagnosis. They reported that the randomized MesoVATS trial found no one-year survival advantage for partial pleurectomy over talc pleurodesis. They reported that the MARS pilot trial showed no survival benefit, and possibly harm, from adding extrapleural pneumonectomy (EPP) to chemotherapy. They added that not all the scientific community shared its conclusions, citing major limitations of the data, and that the debate continued. No randomized trial had compared EPP with lung-sparing surgery. They also described two illustrative cases: a 40-year-old man treated with EPP and a 73-year-old woman treated with extended pleurectomy decortication. The authors concluded that EPP should only be considered in the fittest patients with early stage epithelioid disease, with lung-sparing radical surgery proposed otherwise. They added that remaining doubts can only be settled by randomized 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: Narrative (non-systematic) literature review and expert opinion, with two illustrative case descriptions
• Who was studied: Published studies on surgery for malignant pleural mesothelioma found through PubMed, favouring recent English-language publications in high-impact journals, plus two illustrative patient cases
• Exposure: Not studied. The article concerns surgical treatments for malignant pleural mesothelioma (VATS, mediastinoscopy, talc pleurodesis, partial pleurectomy, extrapleural pneumonectomy, extended pleurectomy decortication), not asbestos exposure.
• Main results:
  • The authors wrote that there was compelling evidence for using VATS to reach a definitive diagnosis of malignant pleural mesothelioma.
  • The authors reported that in the randomized MesoVATS trial, partial pleurectomy gave no survival advantage at one year compared with talc pleurodesis. It also exposed patients to a higher risk of postoperative complications.
  • The authors reported that the MARS pilot trial (chemotherapy plus EPP versus chemotherapy alone) showed no survival benefit from surgery, and possibly that adding EPP was detrimental.
  • The authors noted that the MARS trial's conclusions were not shared by all the scientific community, which highlighted major limitations of the data, and that the debate goes on.
  • The authors reported that the Swiss SAKK 17/04 trial failed to demonstrate a clear survival advantage from high-dose radiotherapy after EPP.
  • The authors stated that no randomized trials comparing EPP with EPD or any other radical lung-sparing approach had been performed.
  • The authors stated that many recent retrospective series showed no difference, or better survival, with lung-sparing surgery compared with EPP.
  • The authors stated that clinical doubt remains about the relative benefits of radical surgery and systemic chemotherapy, and that only prospective randomized trials can address it.
  • Illustrative case 1 was a 40-year-old man with left epithelioid mesothelioma.
  • Case 1 underwent a left EPP. He was alive and free from detectable disease progression 6 months after surgery.
  • Illustrative case 2 was a 73-year-old woman with epithelioid malignant pleural mesothelioma.
  • Case 2 underwent a right extended pleurectomy decortication without intraoperative complication. Final pathology showed stage III disease (pT3N2).
• The authors' conclusion: The authors concluded that EPP should only be considered in the fittest patients with early stage epithelioid disease. In all other cases they proposed lung-sparing radical surgery, citing its lower morbidity, similar long-term survival and better potential physiological outcomes.
• Limitations the authors state:
  • The authors stated that a systematic review was not possible because high-grade evidence on the topic was lacking.
  • The authors stated that most EPP series are affected by selection bias, because only patients with the best performance status can tolerate the operation.
  • The authors stated that the apparent survival benefit from additional chemotherapy may be due to selection bias.

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: Thoracic Surgery, Mesothelioma, Pleural Mesothelioma, Thoracoscopy, Pleural Cavity, Mediastinoscopy, Talc Pleurodesis, Pneumonectomy.

Related studies

• A survey of opinions and beliefs concerning surgery for malignant pleural mesothelioma amongst 802 members of the European Association for Cardio-Thoracic Surgery (EACTS), the European Society of Thoracic Surgeons (ESTS) and the Society of Thoracic Surgeons (STS) — T. Treasure, E. Internullo, et al. (2011)
• Expert opinions of the first italian consensus conference on the management of malignant pleural mesothelioma — C. Pinto, A. Ardizzoni, et al. (2011)
• The Use of Radiation Therapy for the Treatment of Malignant Pleural Mesothelioma: Expert Opinion from the National Cancer Institute Thoracic Malignancy Steering Committee, International Association for the Study of Lung Cancer, and Mesothelioma Applied Research Foundation — D.R. Gomez, A. Rimner, et al. (2019)
• Surgical Management of Malignant Pleural Mesothelioma: An Update of Clinical Evidence — C. Cao, Z. Akhunji, et al. (2015)
• British Thoracic Society Guideline for the investigation and management of malignant pleural mesothelioma — I. Woolhouse, L. Bishop, et al. (2018)
• What is the best approach for surgery of malignant pleural mesothelioma? It is to put our efforts into obtaining trustworthy evidence for practice — T. Treasure (2016)

Browse more research in Expert Review of Respiratory Medicine, or return to medical research.