The staging of malignant pleural mesothelioma: are we any nearer to squaring the circle?

Our plain-English summary of The staging of malignant pleural mesothelioma: are we any nearer to squaring the circle?, by D.A. Waller (European Journal of Cardio-thoracic Surgery, 2016).

The study

• Author: D.A. Waller
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2016;49(6):1648-9
• Type of article: Editorial, Comment
• Cited by: 6 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Summary of the article

This editorial comment, by a thoracic surgeon in Leicester, UK, discussed the staging of malignant pleural mesothelioma (MPM). It responded to a study by Kircheva et al. that proposed resected specimen weight and volume as predictors of survival. The author argued that accurate staging at presentation was essential for deciding who would benefit from radical surgery and for designing and interpreting clinical trials. He noted that current T descriptors were descriptive and best suited to surgical and pathological staging. He reviewed pretreatment imaging measures, including tumour thickness, CT-based tumour volume and FDG-PET total glycolytic volume. He identified limitations in the Kircheva study: a high proportion (49%) of non-epithelioid tumours, acceptance of 5% R2 resection, a low rate of pN0 disease (40%) despite 71% of cases being staged pT3/4, 15% of cases staged pNX, and no description of the nodal dissection technique. He argued that nodal metastasis remained key to prognosis in epithelioid MPM and that such disease should be classed simply as node-negative or node-positive. He supported histological nodal staging by endobronchial ultrasound or cervical mediastinoscopy before radical surgery. He concluded that biological markers would eventually supersede anatomical staging. For now, he said, surgeons should rely on accurate imaging, invasive preoperative nodal staging and intraoperative systematic nodal dissection. Specimen weight might become a useful adjunct after further validation.

PubMed has no abstract for this study, and the article doesn't print one. We wrote this summary from the full article with the help of AI. It is not the authors' wording.

In plain English

This editorial comment on staging malignant pleural mesothelioma reported no new patient data. It responded to a paper by Kircheva et al., which supported tumour dimensions over local relations in staging criteria and advocated tumour weight, in the author's view likely useful only for planning adjuvant therapy. The author described limitations that detracted from its conclusions. Its cases were 49% non-epithelioid, unusually high for a surgical series according to the author. Surgeons aimed only for maximal debulking, accepting a 5% R2 resection. Only 40% of cases were node-negative (pN0), although 71% were staged pT3/4. Another 15% were staged pNX, suggesting too little node material to analyse. The author argued that lymph node spread is likely key to estimating prognosis in epithelioid mesothelioma, and encouraged examining node tissue rather than relying on CT scans. Asbestos was mentioned only in a hypothesis that pleural fluid carries inhaled asbestos fibres (in relation to cause) and/or shed tumour cells within the chest. The author concluded that surgeons should combine accurate imaging, invasive nodal staging before surgery and systematic nodal dissection during it.

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: Editorial comment (expert opinion responding to another paper); no original data
• Who was studied: No patients were studied. The editorial comments on a surgical series of malignant pleural mesothelioma patients reported by Kircheva et al.
• Exposure: Not studied. Inhaled asbestos fibres are mentioned only in passing. They appear in a 'gravitational' hypothesis in which pleural fluid carries both inhaled asbestos fibres (in relation to aetiology) and/or shed tumour cells within the chest.
• Main results:
  • The author noted that Kircheva et al. supported tumour dimensions over local relations in staging criteria. The author considered their advocacy of tumour weight likely useful only for planning adjuvant therapy.
  • The author noted that 49% of cases in the Kircheva et al. series were non-epithelioid, which the author called unusually high for a surgical series.
  • The author noted that Kircheva et al. aimed only for maximal debulking, accepting a 5% R2 resection, rather than macroscopic complete resection.
  • The author noted that in the Kircheva et al. series, node-negative (pN0) disease was 40%. The author found this surprisingly low given that 71% of cases were staged pT3/4.
  • The author noted that 15% of cases in the Kircheva et al. series were staged pNX. The author took this to suggest insufficient nodal material for analysis.
• The authors' conclusion: The author argued, contrary to Kircheva et al., that nodal metastasis is likely key to estimating prognosis in epithelioid mesothelioma. The author encouraged histological nodal staging and called for invasive preoperative nodal staging and intraoperative systematic nodal dissection. In the author's view, specimen weight may help predict outcome after further validation.

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: Staging, Pleural Mesothelioma, Clinical Trial, Non-epithelioid, Metastasis, Prognosis, Epithelioid, Node-negative.

Related studies

• Recommendations for uniform definitions of surgical techniques for malignant pleural mesothelioma: a consensus report of the international association for the study of lung cancer international staging committee and the international mesothelioma interest group — D. Rice, V. Rusch, et al. (2011)
• The importance of surgical staging in the treatment of malignant pleural mesothelioma — V.W. Rusch, E. Venkatraman (1996)
• The IASLC Mesothelioma Staging Project: Proposals for the M Descriptors and for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Mesothelioma — V.W. Rusch, K. Chansky, et al. (2016)
• A proposed new international TNM staging system for malignant pleural mesothelioma from the International Mesothelioma Interest Group — V.W. Rusch (1996)
• The IASLC Mesothelioma Staging Project: Proposals for Revisions of the N Descriptors in the Forthcoming Eighth Edition of the TNM Classification for Pleural Mesothelioma — D. Rice, K. Chansky, et al. (2016)
• Positron emission tomography with f18-fluorodeoxyglucose in the staging and preoperative evaluation of malignant pleural mesothelioma — D.B. Schneider, C. Clary-Macy, et al. (2000)

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