Types of surgery post-neoadjuvant chemotherapy for pleural mesothelioma

Our plain-English summary of Types of surgery post-neoadjuvant chemotherapy for pleural mesothelioma, by K. Kuribayashi, H. Doi, T. Kijima (Expert Review of Respiratory Medicine, 2019).

The study

• Authors: K. Kuribayashi, H. Doi, T. Kijima
• Journal: Expert Review of Respiratory Medicine
• Published: 2019;13(12):1189-1194
• Type of article: Review
• Cited by: 6 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: The surgical arm of the Mesothelioma and Radical Surgery (MARS) trial involved a multimodal approach, with combined therapy consisting of chemotherapy, complete gross resection, and radiation therapy. However, the MARS trial did not compare surgery with chemotherapy, and the survival and quality of life outcomes of this trial's surgical arm were inferior to those of the non-surgical arm. Methods for achieving complete gross resection (macroscopic complete response [MCR]) include extrapleural pneumonectomy (EPP), wherein the pleura, lung, diaphragm, and pericardium are removed en bloc, and pleurectomy/decortication (P/D), wherein the affected lung is preserved. Nonetheless, the most effective therapy remains unclear.Areas covered: Here, surgery post-neoadjuvant chemotherapy for malignant pleural mesothelioma with either EPP or P/D has been discussed, along with trimodal and bimodal therapies.Expert opinion: With the development of post-P/D radiation therapy, it is currently possible to truly compare EPP with P/D. Moreover, R0 resection cannot be achieved with either EPP or P/D; thus, both must incorporate debulking, although the two procedures are largely incompatible. Therefore, there is a need to rebuild the status of surgery as a multimodal therapy.

In plain English

This article was a review, not a new study. The authors discussed surgery after chemotherapy given before an operation (neoadjuvant chemotherapy) for malignant pleural mesothelioma. They compared two operations: extrapleural pneumonectomy (EPP), which removes the pleura, lung, diaphragm and pericardium together, and pleurectomy/decortication (P/D), which keeps the affected lung. They noted that no randomized trials had compared EPP with P/D, and that there was no reliable evidence that surgery itself is beneficial for this disease. They described a published meta-analysis of 7 studies. In it, median survival was comparable for EPP and P/D, but surgical mortality (6.8% vs. 2.9%) and adverse event rates (62.0% vs. 27.9%) were higher for EPP. They wrote that neither operation can remove the tumor with clear margins. They also reviewed studies of a radiation technique (IMRT) given after P/D. The authors concluded that there is currently no clear indication for surgery for this disease. They said research should give priority to the feasibility of combining chemotherapy, complete removal of visible tumor, and radiation therapy. The article did not study asbestos exposure.

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
• Who was studied: No patients were studied directly. The review discussed published studies and trials of surgery for malignant pleural mesothelioma (MPM).
• Exposure: Not an asbestos-exposure study. The review covered treatments: extrapleural pneumonectomy (EPP), pleurectomy/decortication (P/D), chemotherapy, and radiation therapy including intensity-modulated radiation therapy (IMRT).
• Main results:
  • The authors reported that no randomized trials had compared EPP and P/D.
  • The authors wrote that there is no reliable evidence that surgery itself is truly beneficial for MPM.
  • The authors cited a published systematic review and meta-analysis of 7 studies comparing the two operations. Median survival was comparable (12–22 months for EPP vs. 13–29 months for P/D). Surgical mortality was higher for EPP (6.8% vs. 2.9%, P = 0.02), and so were adverse event rates (62.0% vs. 27.9%, P < 0.0001).
  • The authors stated that resection with negative margins (R0) cannot be achieved with either EPP or P/D, so the goal of surgery is limited to R1 resection (gross total resection).
  • The authors cited a survey of thoracic surgeons with a special interest in MPM. In it, 90% thought EPP and 68% thought extended P/D could provide adequate cytoreduction, compared with only 23% for P/D.
  • The authors cited a phase II study of hemithoracic pleural IMRT after chemotherapy and P/D. Of the 27 patients enrolled, 6 had grade 2 and 2 had grade 3 radiation pneumonitis. No grade 4 or 5 cases were noted.
• The authors' conclusion: The authors concluded that there is currently no clear indication for MPM surgery, because there is no scientific evidence that surgery improves prognosis. They found that predictors for choosing between EPP and P/D have not been identified. They believed research should give priority to the feasibility of trimodality therapy (chemotherapy, macroscopic complete resection, and radiation therapy).
• Limitations the authors state:
  • The authors noted that the evidence base for MPM treatment is limited, with very few randomized controlled trials.
  • The authors cautioned that direct comparisons of EPP and P/D in the literature are affected by many biases, such as differences in the chemotherapy and radiation therapy given alongside 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: Neoadjuvant Chemotherapy, Pleural Mesothelioma, Mesothelioma, Chemotherapy, Quality of Life, Extrapleural Pneumonectomy (EPP), Pleura, Diaphragm.

Related studies

• Treatment of malignant pleural mesothelioma with chemotherapy preceding versus after surgical resection — V. Verma, C.A. Ahern, et al. (2019)
• Importance of excision repair cross-complementation group 1 and ribonucleotide reductase M1 as prognostic biomarkers in malignant pleural mesothelioma treated with platinum-based induction chemotherapy followed by surgery — L. Frischknecht, M. Meerang, et al. (2015)
• Near-Infrared Intraoperative Imaging Can Successfully Identify Malignant Pleural Mesothelioma After Neoadjuvant Chemotherapy — J.D. Predina, A. Newton, et al. (2017)
• Complications and Predictive Factors for Air Leak > 10 Days with Neoadjuvant Chemotherapy Followed by Pleurectomy/Decortication for Malignant Pleural Mesothelioma — A. Nakamura, N. Kondo, et al. (2021)
• Cytoreductive surgery and post-operative heated pleural chemotherapy for the management of pleural surface malignancy — K. Kodama, M. Higashiyama, et al. (2013)
• 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)

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