Trimodality management of malignant pleural mesothelioma

Our plain-English summary of Trimodality management of malignant pleural mesothelioma, by G. Maggi, C. Casadio, R. Cianci, et al (European Journal of Cardio-thoracic Surgery, 2001).

The study

• Authors: G. Maggi, C. Casadio, R. Cianci, O. Rena, E. Ruffini
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2001;19(3):346-50
• Cited by: 64 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objective: We reviewed our experience with trimodality management of malignant pleural mesothelioma (MPM).

Methods: From September 1998 to August 2000, 32 consecutive patients with histological diagnosis of MPM underwent trimodality therapy, including surgery followed by adjuvant chemotherapy and radiation therapy. Surgery consisted of pleurectomy/decortication (P/D) or pleural-pericardial-pneumonectomy and diaphragm (PPPD). Pre-operative staging according to the Brigham Staging System was accomplished using computed tomography (CT) and magnetic resonance imaging (MRI); patients with evident extrapleural spread were excluded.

Results: Our series included 21 men and 11 women with a median age of 53.5 years (range 40-69). Histologically, there were 26 epithelial, four mixed and two sarcomatous MPM. Post-surgical staging was as follows: six patients were at Stage I; of these, two received a P/D and four a PPPD. Ten patients were at Stage II and all received a PPPD; 16 patients were at Stage III (under-staged pre-operatively): of these, nine patients presented extrapleural lymph node metastases (N2) and all received a PPPD, seven patients presented with chest wall or mediastinal invasion (T4) with macroscopic residual tumour, and all received a de-bulking P/D. We observed major complications in ten patients: six bleeding, two respiratory insufficiency and two nerve paralysis. There were two perioperative deaths (6.25% mortality). Twenty-seven patients out of 30 surviving surgery had a follow-up greater than 6 months; 21 patients out of 27 are alive with a median follow-up of 12.5 months.

Conclusions: (1) Trimodality therapy is feasible in selected patients with MPM and has an acceptable operative mortality rate. (2) Our current pre-operative staging based on CT/MRI looks rather inaccurate and needs to be improved. (3) The high rate of post-surgical N2 patients or with diffusion to the inferior surface of the diaphragm may suggest the use of routine mediastinoscopy and laparoscopy for a more appropriate patient selection.

In plain English

Surgeons at the University of Torino, Italy, reported their experience with trimodality therapy for malignant pleural mesothelioma. From September 1998 to August 2000, 32 patients (21 men, 11 women) had surgery; 27 completed chemotherapy and radiation therapy. Nine had a pleurectomy/decortication and 23 a pleural-pericardial-pneumonectomy with diaphragm resection (PPPD). Asbestos exposure was not reported. After surgery, 16 patients (50%) were at Stage III; the authors found that pre-operative CT and MRI had missed extrapleural lymph node involvement or spread. Ten of 32 patients had major complications; two (6.25%) died within 30 days. Of 27 patients followed beyond 6 months, eight died, five from peritoneal spread of mesothelioma, and 21 were alive at a median follow-up of 12.5 months; these counts total 29, which the article does not explain. The authors concluded that the therapy was feasible in selected patients with acceptable operative mortality, but that pre-operative staging was inaccurate. They suggested routine mediastinoscopy and laparoscopy to select patients better. They reported that survival differences between stages were not significant, probably because of the small series and limited follow-up.

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: Single-centre review of the surgeons' own consecutive series of patients treated with trimodality therapy (surgery, chemotherapy, radiation therapy)
• Who was studied: 32 patients with epithelial or mixed type malignant pleural mesothelioma treated at the Department of Thoracic Surgery, University of Torino, Italy, from September 1998 to August 2000. There were 21 men and 11 women, with a median age of 53.5 years (range 40 to 69).
• Exposure: The article does not report the patients' asbestos exposure. The treatment studied was surgery: pleurectomy/decortication (P/D) or pleural-pericardial-pneumonectomy with diaphragm resection (PPPD). Surgery was followed by intravenous chemotherapy (paclitaxel and carboplatin) and radiation therapy (about 30 Gy to the hemithorax and mediastinum, with boosts, to a total maximum of 55 Gy).
• Main results:
  • Tumour type: 26 patients had epithelial type, four had mixed-cell type, and two had sarcomatous type mesothelioma (these two had been considered mixed before the operation).
  • Staging after surgery: 6 patients (18.7%) were at Stage I, 10 (31%) at Stage II, and 16 of 32 (50%) at Stage III of the Brigham Staging System.
  • Pre-operative CT or MRI did not reveal the extrapleural lymph node involvement or extrapleural spread that was found at surgery.
  • Operations performed: 9 P/D (28%), of which 7 left gross residual disease, and 23 PPPD (72%).
  • Of the 32 patients who had surgery, 27 completed the post-surgical chemotherapy and radiation therapy.
  • Major complications within 30 days occurred in 10 of 32 patients (31.25%). These were six with bleeding, two with acute respiratory insufficiency, one with a bronchopleural fistula and one with vocal cord paralysis.
  • Perioperative deaths: 2 of 32 patients (6.25%). One died of acute respiratory insufficiency (ARDS) on day 5 and one of pneumonia of the remaining lung on day 14.
  • Of the 30 patients who survived surgery, 27 had follow-up longer than 6 months. The article states that eight of these 27 died (median survival 9.5 months) and that 21 patients were alive at a median follow-up of 12.5 months. Eight plus 21 is 29, not 27, and the article does not reconcile these counts.
  • Causes of death among the eight patients who died after discharge: five from peritoneal spread of mesothelioma with ascites, two from distant metastases, and one from local recurrence.
  • Survival at 10 months by stage was 100% for Stage I, 80% for Stage II and 75% for Stage III. The authors reported that these differences were not statistically significant in their series.
  • Side effects among the 27 patients who completed chemotherapy and radiation therapy: 24 had gastrointestinal effects, 24 had hair loss, 6 had neutropenia and 4 had somnolence. The authors reported that all were reversible.
• The authors' conclusion: The authors concluded that trimodality therapy is feasible in selected patients with malignant pleural mesothelioma and has an acceptable operative mortality rate. They also concluded that their pre-operative staging with CT and MRI was rather inaccurate and needs to be improved.
• Limitations the authors state:
  • The authors attributed the lack of significant survival differences between stages to the small number of patients and the limited follow-up.
  • The authors stated that too many operated patients turned out to be at Stage III, which they linked to inaccurate pre-operative staging.
  • The authors suggested that routine mediastinoscopy and laparoscopy may be needed to select patients more appropriately.
  • None of the patients who later died of peritoneal disease had received laparoscopy before the operation. The authors thought the disease was more probably present before surgery.

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, Trimodality Therapy, Chemotherapy, Pleurectomy/Decortication (P/D), Pericardial, Pneumonectomy, Diaphragm, Staging.

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• 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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• Survival after trimodality therapy for malignant pleural mesothelioma: Radical Pleurectomy, chemotherapy with Cisplatin/Pemetrexed and radiotherapy — S. Bölükbas, C. Manegold, et al. (2011)
• Chemotherapy management of malignant pleural mesothelioma: a phase II study comparing two popular chemotherapy regimens — E.E. Habib, E.S. Fahmy (2013)
• Trimodality treatment of malignant pleural mesothelioma — H.F. Batirel, M. Metintas, et al. (2008)

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