Proposal for a new local recurrence score in patients with recurrent malignant pleural mesothelioma

Our plain-English summary of Proposal for a new local recurrence score in patients with recurrent malignant pleural mesothelioma, by O. Lauk, T. Neuer, B. Battilana, et al (Journal of Thoracic Disease, 2022).

The study

• Authors: O. Lauk, T. Neuer, B. Battilana, I. Inci, K. Furrer, W. Weder, M. Hashimoto, I. Opitz
• Journal: Journal of Thoracic Disease
• Published: 2022;14(8):2835-2844
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Malignant pleural mesothelioma (MPM) is associated with high rates of local recurrence (LR) up to 75%. Second line treatment should be applied tailored to relapse pattern. We aimed to establish a new score for LR pattern with prognostic impact in this observational study of retrospective nature.

Methods: MPM patients with LR after surgery, verified by serial imaging during follow-up visits or biopsy were included in a retrospective analysis using a new local recurrence score (LRS). We divided the thoracic cavity into six sections and calculated the LRS according to the tumor burden. We assessed the impact on survival after recurrence using cox regression model.

Results: From 2001 until 2017, 128 consecutive MPM patients with LR who underwent macroscopic complete resection (MCR) by extrapleural pneumonectomy (EPP, n=61) or by (extended) pleurectomy/decortication [(E)PD, n=67], were included in the present analysis; 104 patients received second line therapy. Patients with chest wall (CW) recurrence had the shortest survival after recurrence (9 vs. 16 months, P=0.05) as well as patients with affected lymph nodes (LN) (9 vs. 17 months, P=0.02). In subgroup analysis, the (E)PD group had a significantly higher LRS (P≤0.001) despite a longer survival time after recurrence of 12.4 months (IQR, 6.45-20.32) compared to 9.3 months (IQR, 2.93-17.40, EPP group) (P=0.04). Patients with LRS ≤4 had a longer survival undergoing radiotherapy or local surgery for second line treatment whereas patients with LRS >4 only if they underwent chemotherapy.

Conclusions: LRS might be a useful prognostic tool in MPM patients with LR after multimodality therapy to guide second line treatment allocation.

2022 Journal of Thoracic Disease. All rights reserved.

In plain English

This retrospective Zurich study proposed a local recurrence score (LRS) for malignant pleural mesothelioma returning in the chest after surgery. Of 249 patients with macroscopic complete resection in 2001–2017, 165 had local recurrence; 128 were analysed: 61 after extrapleural pneumonectomy and 67 after (extended) pleurectomy/decortication. The chest was divided into six regions: five scored 0 to 3 by lesion size on CT, and lymph nodes 0 to 2 as none, solitary or multiple, for 0 to 17 in total. Median survival after recurrence was 10.6 months overall. With chest wall recurrence, median survival was 9 months (95% CI 4.90 to 13.10) versus 16 months (95% CI 10.19 to 21.81) without (P=0.05). With mediastinal lymph node recurrence it was 9 months (95% CI 6.50 to 11.50) versus 17 months (95% CI 14.37 to 19.63) without (P=0.02). Survival was longer with a score of 4 or less than above 4 (hazard ratio 1.68; 95% CI 1.07 to 2.60). The authors concluded it needs prospective evaluation. They noted the small, retrospective cohort and excluded patients as limitations. Asbestos exposure was not examined.

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: Retrospective observational study of a single institution's prospective database
• Who was studied: 128 patients with malignant pleural mesothelioma who had macroscopic complete resection and later local recurrence, treated 2001–2017 at University Hospital Zurich. Of these, 61 had extrapleural pneumonectomy (EPP) and 67 had (extended) pleurectomy/decortication ((E)PD). They came from 165 patients with local recurrence among 249 who achieved macroscopic complete resection.
• Exposure: Asbestos exposure was not studied. The study examined where local recurrence occurred and how large it was, and which second-line treatment patients received. Recurrence was scored in six chest regions: chest wall, mediastinum, diaphragm, lung parenchyma, neo-pleural thickening and lymph nodes. Five regions were scored 0–3 by lesion size. Lymph nodes were scored by absent, single or multiple involvement.
• Main results:
  • Median post-recurrence survival for all 128 patients was 10.6 months (IQR 4.8 to 18.5).
  • Median post-recurrence survival was 9 months (95% CI 4.90 to 13.10) for the 61 patients with chest wall recurrence. It was 16 months (95% CI 10.19 to 21.81) for the 67 without (P=0.05).
  • Median post-recurrence survival was 9 months (95% CI 6.50 to 11.50) for the 71 patients with mediastinal lymph node recurrence. It was 17 months (95% CI 14.37 to 19.63) for the 56 without (P=0.02).
  • Across both surgery types, post-recurrence survival was longer in patients with LRS 4 or less than in patients with LRS above 4 (HR 1.68; 95% CI 1.07 to 2.60; P=0.023).
  • The median LRS was higher in the (E)PD group than in the EPP group (6 vs. 2, P less than 0.001).
  • Median post-recurrence survival was 12.4 months (IQR 6.45 to 20.32) in the (E)PD group and 9.3 months (IQR 2.93 to 17.40) in the EPP group. The article body gives P=0.03.
  • 104 patients (81.2%) received second-line treatment. Chemotherapy showed a favorable effect for patients with LRS above 4 (P=0.002). Patients with LRS 4 or less showed longer survival after radiotherapy or local surgery.
• The authors' conclusion: The authors concluded that this is the first report to establish a local recurrence pattern and score with a potential prognostic impact on second-line treatment allocation and survival. They added that it needs further evaluation in a prospective study.
• Limitations the authors state:
  • The limited number of patients, the retrospective design and the two different initial surgical approaches call for cautious interpretation.
  • 37 of 165 patients were excluded for insufficient data, which may be a source of bias.
  • Pathological factors were not included in the analysis.
  • Coronal or sagittal CT slices were missing for some referred patients, so all measurements were made on axial slices only.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Biopsy, Tumor Burden, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D), Chemotherapy, Multimodal Therapy.

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