Malignant Pleural Mesothelioma Nodal Status: Where Are We at?

Our plain-English summary of Malignant Pleural Mesothelioma Nodal Status: Where Are We at?, by S. Ricciardi, F. Carleo, M.O. Jaus, et al (Journal of Clinical Medicine, 2021).

The study

• Authors: S. Ricciardi, F. Carleo, M.O. Jaus, M. Di Martino, L. Carbone, A. Ricci, G. Cardillo
• Journal: Journal of Clinical Medicine
• Published: 2021;10(21)
• Type of article: Review
• Cited by: 3 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Due to the lack of both prospective trial and high-volume retrospective studies, the management of clinical N+ malignant pleural mesothelioma (MPM) patients remains highly debated. Node positive patients show poor survival compared with node-negative ones; thus, lymph node staging appears crucial in determining treatment strategy. Notwithstanding the improvement in pre-treatment staging and the update on lymph node classification in the 8th edition of TNM, several open controversies remain on N parameter. How should we stage suspected N+ patients? How should we treat node positive patients? Which is the definition of a "resectable patient"? Is the site or the number the main prognostic factor for node positive patients? The aim of our narrative review is to analyse the existing relevant literature on lymph node status in MPM.

In plain English

This was a narrative review of research on lymph node involvement in malignant pleural mesothelioma (MPM), not a new study. The authors searched MEDLINE through PubMed in August 2021 for English-language full-text articles, excluding case reports and congress abstracts. The review did not discuss asbestos exposure. Among cited studies, an IASLC database analysis of 2432 cases found worse survival in pN1 or pN2 than pN0 patients, with no difference between pN1 and pN2. Cited studies reported that pathological staging found more nodal disease than clinical staging in 33% of patients staged both ways, and gave cervical mediastinoscopy a sensitivity of 28 to 36%. In a cited national database study of 2548 node-positive patients (7th edition staging), median overall survival was 10.0 months (8.7 to 11.6) for N1, 9.1 months (8.7 to 9.6) for N2 and 8.5 months (7.0 to 10.1) for N3. The authors concluded that nodal status is a strong prognostic factor, but whether node location or number matters most is debated. They noted no prospective trials exist for clinically node-positive MPM and called for large randomized trials.

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 published literature
• Who was studied: Published articles on lymph node status in malignant pleural mesothelioma, found in MEDLINE through PubMed in August 2021. The search was limited to English full-text articles and excluded case reports, unpublished papers and congress abstracts. The number of articles reviewed is not stated.
• Main results:
  • In the IASLC database of 2432 cases (a cited study), patients with pN1 or pN2 tumours had worse survival than pN0 patients. There was no survival difference between pN1 and pN2 patients. This led the 8th edition of TNM to merge the old N1 and N2 into one group.
  • Cited data showed that clinical nodal staging did not accurately predict pathologic status. Nodal upstaging was found in 33% of patients staged both clinically and pathologically, and downstaging in 6%.
  • Cited reports gave cervical mediastinoscopy a sensitivity of 28 to 36% and a false negative rate of 22 to 53% in MPM staging.
  • In a cited analysis, endobronchial ultrasound (EBUS) had a sensitivity of 58% versus 28% for cervical mediastinoscopy. The negative predictive values were 49% and 57%, respectively.
  • In a cited National Cancer Database study of 2548 node-positive MPM patients (Verma et al., 7th edition TNM), median overall survival was 10.0 months (8.7 to 11.6) for N1, 9.1 months (8.7 to 9.6) for N2 and 8.5 months (7.0 to 10.1) for N3.
  • In a cited study of 99 patients (Hysi et al.), a lower metastatic lymph node ratio (13% or less) was associated with longer median survival: 19.9 versus 11.7 months, p = 0.01. Overall survival was not associated with the number of involved or removed nodes.
• The authors' conclusion: The authors concluded that nodal status is a strong prognostic factor for median survival. Whether the location or the number of positive nodes is the main prognostic factor remains debated.
• Limitations the authors state:
  • The authors stated that there are no prospective trials or high-volume retrospective studies of patients with clinically node-positive MPM.
  • The authors stated that large prospective randomized trials are needed to establish an evidence-based approach to staging and treating node-positive patients.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Node-negative, Staging.

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