A Trimodality, Four-Step Treatment including Chemotherapy, Pleurectomy/Decortication and Radiotherapy in Early-Stage Malignant Pleural Mesothelioma: A Single-Institution Retrospective Case Series Study

Our plain-English summary of A Trimodality, Four-Step Treatment including Chemotherapy, Pleurectomy/Decortication and Radiotherapy in Early-Stage Malignant Pleural Mesothelioma: A Single-Institution Retrospective Case Series Study, by G. Vicidomini, C.M. Della Corte, A. Noro, et al (Cancers, 2021).

The study

• Authors: G. Vicidomini, C.M. Della Corte, A. Noro, R. Di Liello, S. Cappabianca, A. Fiorelli, V. Nardone, G. Messina, G. Viscardi, A. Sangiovanni, R. Monti, M. Accardo, F. Morgillo, F. Ciardiello, R. Franco, M. Santini
• Journal: Cancers
• Published: 2021;14(1)
• Cited by: 4 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Multimodality treatment is considered the best treatment strategy for malignant pleural mesothelioma (MPM). However, the ideal combination of them is still a matter of controversy. Here, we report a case series of MPM treated with a trimodality approach: induction chemotherapy (CT), pleurectomy/decortication (P/D), postoperative radiotherapy (RT) and post-operative CT.

Methods: A retrospective case series of 17 MPM patients treated between 2013 and 2020 is presented. Patients had epithelial or mixed MPM diagnosed by video-assisted thoracoscopy and pathologic IMIG stage I or II disease. Treatment details and radiological data were collected. Induction therapy consisted of combination of cisplatin and pemetrexed, every 21 days for two cycles. P/D was performed 4-6 weeks after induction CT, post-operative RT 3-6 weeks after surgery, while post-operative CT was given 4-6 weeks after RT, with the same schedule of induction.

Results: All patients showed objective response or stability of disease at the restaging following induction CT and underwent surgery by posterolateral thoracotomy. There were two cases of cardiac arrest as major intraoperative complication, both resolved by manual cardiac massage. Minor complications included one hemidiaphragm elevation, 1 anemia requiring blood transfusion, one wound infection, and two persistent air leaks. Median overall survival was 32.1 months, median progression free survival was 23.7 months.

Conclusions: These results suggest the feasibility of these trimodality treatment scheme for early stage MPM patients. Larger series and long-term prospective studies are needed to confirm the validity of this strategy.

In plain English

This was a retrospective case series from one hospital in Naples, Italy. Among 97 patients diagnosed with malignant pleural mesothelioma there from 2013 to 2020, the authors identified 17 with stage I or II epithelial or biphasic disease. These patients had completed a four-step treatment: two cycles of cisplatin and pemetrexed chemotherapy, surgery to remove the pleura (pleurectomy/decortication), radiotherapy, then two more chemotherapy cycles. Asbestos exposure was recorded for 12 of the 17. Two patients had cardiac arrest during surgery, both resolved by manual cardiac massage, and no patient died within 90 days of surgery. In 12 of 17 the resection was classed as complete (R0/R1); five had residual disease (R2). Radiotherapy caused no grade 3 or worse side effects, but 8 patients had grade 2 lung inflammation (pneumonitis). Disease returned in 14 of 17 patients, mostly near the original site. Median progression-free survival was 23.7 months and median overall survival 32.1 months. Five of 17 were alive at data cut-off. The authors concluded the approach was feasible and warrants further study. They noted that the series was retrospective and had no comparison group.

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-institution retrospective case series with no control group
• Who was studied: 17 patients with epithelial or biphasic malignant pleural mesothelioma, pathologic IMIG stage I or II. They were identified among 97 patients diagnosed at the University of Campania "Luigi Vanvitelli", Naples, Italy, from 2013 to 2020. Median age was 66 years (range 58 to 73), and 12 (70.6%) were male.
• Exposure: The treatment studied was: two cycles of induction cisplatin (75 mg/m2) and pemetrexed (500 mg/m2) every 21 days; pleurectomy/decortication 4 to 6 weeks later; postoperative radiotherapy of 50 Gy in 25 fractions 3 to 6 weeks after surgery, with a 10 Gy boost for patients with residual disease; then two cycles of platinum-pemetrexed chemotherapy 4 to 6 weeks after radiotherapy. Asbestos exposure was recorded as yes in 12 of 17 patients (70.6%).
• Main results:
  • Asbestos exposure was recorded as yes for 12 of the 17 patients (70.6%) and no for 5 (29.4%).
  • After induction chemotherapy there were no complete responses. A metabolic response was seen in 10 of 17 patients (58.8%).
  • During surgery, two patients had cardiac arrest, both resolved by manual cardiac massage. Surgical complications occurred in 7 of 17 patients (41.2%).
  • No patient died within 30 or 90 days after surgery.
  • In 12 of 17 patients (70.6%) the resection was classed as complete (R0/R1). Five patients (29.4%) had residual disease (R2).
  • Postoperative radiotherapy caused no complications of grade 3 or higher. Grade 2 pneumonitis occurred in 8 patients (47%) and grade 1 pneumonitis in 13 patients (76%).
  • Disease recurred in 14 of 17 patients (82%). In 12 of these 14 (86%) the recurrence was mostly loco-regional.
  • For the whole group, median progression-free survival was 23.7 months (range as printed 20.2 to 35.2 months). Median overall survival was 32.1 months (range as printed 28.7 to 57.8 months).
  • At data cut-off, 5 of 17 patients (29.4%) were still alive.
  • The authors reported that all deaths were related to disease progression.
  • Progression-free survival did not differ significantly between R0/R1 and R2 patients. The authors described a trend toward longer overall survival in the R0/R1 group: 32.1 months versus 21.8 months in R2 patients.
• The authors' conclusion: The authors concluded that the trimodality four-step approach in early-stage (I and II) malignant pleural mesothelioma warrants further investigation because they found it feasible in clinical practice. They stated that larger prospective trials with control groups are needed to confirm benefit.
• Limitations the authors state:
  • The data were retrospective and descriptive, and there was no control group.
  • There were no translational correlative studies of tumor biology.
  • Patients received different treatments after recurrence, which could affect the overall survival figures.
  • Variability between patients was high because they were not selected prospectively.

Topics

Medical terms in this study, explained in our Lexicon: Chemotherapy, Pleurectomy/Decortication (P/D), Pleural Mesothelioma, Thoracoscopy, IMIG, Cisplatin, Pemetrexed (Alimta), Thoracotomy.

Related studies

• Is less also better? A single-institution experience on treatment of early stage Malignant Pleural Mesothelioma — P. Bertoglio, M.C. Ambrogi, et al. (2017)
• A randomised phase II study of extended pleurectomy/decortication preceded or followed by chemotherapy in patients with early-stage pleural mesothelioma: EORTC 1205 — J. Raskin, V. Surmont, et al. (2024)
• Induction Chemotherapy Followed by Pleurectomy Decortication and Hyperthermic Intraoperative Chemotherapy (HITHOC) for Early-Stage Epitheliod Malignant Pleural Mesothelioma-A Prospective Report — S. Bongiolatti, F. Mazzoni, et al. (2021)
• Long-term outcomes following post-operative radiotherapy for Stage I/II testicular seminoma - an Australasian single-institution experience — W.L. Ong, L. Nazareth, et al. (2016)
• Survival after trimodality therapy for malignant pleural mesothelioma: Radical Pleurectomy, chemotherapy with Cisplatin/Pemetrexed and radiotherapy — S. Bölükbas, C. Manegold, et al. (2011)
• Feasibility of multimodality treatment, including pleurectomy decortication, in carefully selected patients with sarcomatoid mesothelioma — M. Lapidot, E. Mazzola, et al. (2026)

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