Treatment of malignant mesothelioma

Our plain-English summary of Treatment of malignant mesothelioma, by M.T. Jaklitsch, S.C. Grondin, D.J. Sugarbaker (World Journal of Surgery, 2001).

The study

• Authors: M.T. Jaklitsch, S.C. Grondin, D.J. Sugarbaker
• Journal: World Journal of Surgery
• Published: 2001;25(2):210-7
• Cited by: 62 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Malignant pleural mesothelioma (MPM) is a rare tumor that predominantly afflicts men over 50 years of age. Nearly 3000 MPMs are reported annually in the United States with the incidence expected to rise into the new millenium. Over the past 40 years, MPM has been unequivocally linked to asbestos exposure worldwide. Recently, however, a new theory on the carcinogenesis of this tumor has been proposed with the isolation of a simian virus (SV 40)-like gene sequence in mesothelioma tumor cells. The clinical presentation of MPM is variable, although most patients typically present with dyspnea, chest pain, or pleural effusion. Obtaining a diagnosis of MPM has been greatly assisted by video-assisted surgery and the use of immunohistochemistry and electron microscopic techniques, which help distinguish MPM from other tumor pathologies such as adenocarcinoma. Computed tomography and magnetic resonance imaging have been also useful for determining tumor burden and resectability. Traditionally, strategies for the treatment of MPM have included supportive care, surgery, radiotherapy, and chemotherapy. Survival with supportive care alone ranges between 4 and 12 months. Single-modality therapy using traditional approaches (surgery, radiotherapy, chemotherapy) alone has failed to improve patient survival significantly. Recently, results using a multimodality approach have been favorable. In particular, cytoreductive surgery (pleuropneumonectomy) followed by sequential chemotherapy and radiotherapy have demonstrated improved survival, especially for patients with epithelial histology, negative resection margins, and no metastases to extrapleural lymph nodes. Innovative therapies such as the use of photodynamic, targeted cytokines and gene therapy are currently being investigated for management of MPM.

In plain English

This article is a review by thoracic surgeons at Brigham and Women's Hospital in Boston of the diagnosis and treatment of malignant pleural mesothelioma. It surveyed published work on surgery, radiation, chemotherapy, supportive care and experimental treatments. It also described the authors' own approach, called trimodality therapy: extrapleural pneumonectomy (removal of the lung and the whole pleural lining), followed by chemotherapy and radiation. The authors summarized the hospital's previously published series of 183 patients treated this way from 1980 to 1997. Of these patients, 75% could recall asbestos exposure. Seven patients (3.8%) died from the operation. Among the 176 who survived surgery, 38% were alive at 2 years and 15% at 5 years, and median survival was 19 months. Patients with epithelial cell type, negative resection margins, or no spread to lymph nodes outside the pleura did better. The 31 patients who had all three of these features had 68% two-year and 46% five-year survival. The authors concluded that only trimodality therapy had consistently improved long-term survival, and only for a subgroup of patients. They noted that it is not curative and that few patients qualify for 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: narrative review of treatment of malignant pleural mesothelioma, including a summary of the authors' institution's previously published trimodality therapy series
• Who was studied: 183 patients with malignant pleural mesothelioma confined to one side of the chest, treated at Brigham and Women's Hospital, Boston, from 1980 to 1997 (43 women and 140 men, aged 31 to 76)
• Exposure: The article studies treatment rather than exposure. In the 183-patient series, 75% could recall asbestos exposure. No fiber types are named.
• Main results:
  • Operative mortality for extrapleural pneumonectomy in the 183-patient series was 3.8% (7 deaths), and major complications occurred in 24.5%.
  • Among the 176 patients who survived surgery, survival was 38% at 2 years and 15% at 5 years, with a median of 19 months.
  • Patients with epithelial cell type had 52% two-year survival, 21% five-year survival, and a median survival of 26 months.
  • Negative resection margins were associated with 44% two-year survival, 25% five-year survival, and a median survival of 23 months.
  • No spread to extrapleural lymph nodes was associated with 42% two-year survival, 17% five-year survival, and a median survival of 21 months.
  • The 31 patients with all three favorable features had 68% survival at 2 years and 46% at 5 years, with a median survival of 51 months.
• The authors' conclusion: The authors concluded that single-modality treatments gave palliation without significantly altering the course of the disease, and that the only consistent improvement in long-term survival, for a subgroup of patients, had been reported with trimodality therapy.
• Limitations the authors state:
  • The authors stated that the regimen is not curative and that, with long enough follow-up, recurrence and death from the disease are nearly universal.
  • The authors noted that only a small number of patients are judged suitable for multimodality treatment.

Topics

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

Medical terms in this study, explained in our Lexicon: Malignant Mesothelioma, Pleural Mesothelioma, Asbestos Exposure, Carcinogenesis, Mesothelioma, Dyspnea, Pleural Effusion, Immunohistochemistry.

Related studies

• Malignant pleural mesothelioma: update on treatment options with a focus on novel therapies — A.R. Haas, D.H. Sterman (2013)
• Photodynamic therapy and the evolution of a lung-sparing surgical treatment for mesothelioma — J.S. Friedberg, R. Mick, et al. (2011)
• Surgery as part of radical treatment for malignant pleural mesothelioma — D.A. Waller, S. Tenconi (2017)
• Mesothelioma: new concepts in diagnosis and management — A.M. Boylan (2000)
• Real-time light dosimetry for intra-cavity photodynamic therapy: Application for pleural mesothelioma treatment — N. Betrouni, C. Munck, et al. (2017)
• Summary of prognostic factors and patient selection for extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma — C. Cao, T.D. Yan, et al. (2011)

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