Relapse Patterns and Tailored Treatment Strategies for Malignant Pleural Mesothelioma Recurrence after Multimodality Therapy

Our plain-English summary of Relapse Patterns and Tailored Treatment Strategies for Malignant Pleural Mesothelioma Recurrence after Multimodality Therapy, by A. Bellini, A. Dell'Amore, S. Terzi, et al (Journal of Clinical Medicine, 2021).

The study

• Authors: A. Bellini, A. Dell'Amore, S. Terzi, G. Zambello, A. Zuin, G. Pasello, F. Calabrese, M. Schiavon, F. Rea
• Journal: Journal of Clinical Medicine
• Published: 2021;10(5)
• Cited by: 14 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

To date, there have been no established therapies for recurrent malignant pleural mesothelioma (MPM) after multimodality treatment. Aims of this retrospective study are to analyze the recurrence pattern, its treatment and to identify the predictors of best oncological outcomes for relapsed MPM, comparing extrapleural pneumonectomy (EPP) vs. pleurectomy/decortication (PD). Study population: 94 patients with recurrence of MPM after multimodality treatment underwent macroscopic complete resection (52.1% with EPP and 47.9% with PD) between July 1994 and February 2020. Distant spread was the most frequent pattern of recurrence (71.3%), mostly in the EPP group, while the PD group showed a higher local-only failure rate. Post-recurrence treatment was administered in 86.2%, whereas best supportive care was administered in 13.8%. Median post-recurrence survival (PRS) was 12 months (EPP 14 vs. PD 8 months, p = 0.4338). At multivariate analysis, predictors of best PRS were epithelial histology (p = 0.026, HR 0.491, IC95% 0.263-0.916), local failure (p = 0.027, HR 0.707, IC95% 0.521-0.961), DFS ≥ 12 months (p = 0.006, HR 0.298, IC95% 0.137-0.812) and post-recurrence medical treatment (p = 0.046, HR 0.101, IC95% 0.897-0.936). The type of surgical intervention seems not to influence the PRS if patients are fit enough to face post-recurrence treatments. In patients with a prolonged disease-free interval, in the case of recurrence the most appropriate treatment seems to be the systemic medical therapy, even in the case of local-only relapse.

In plain English

This retrospective single-center study, at Padova University Hospital in Italy, looked at 94 patients whose malignant pleural mesothelioma came back after multimodality treatment given between July 1994 and February 2020. That treatment combined chemotherapy and surgery, with or without radiotherapy, and the surgery removed all visible tumor. The operation was extrapleural pneumonectomy (EPP) in 49 patients and pleurectomy/decortication (PD) in 45. The article does not report the patients' asbestos exposure. The cancer returned only locally in 27 patients, only at distant sites in 27, and in both in 40. Local-only relapse occurred in 19 of 45 PD patients and 8 of 49 EPP patients. After relapse, 81 patients received further treatment and 13 received best supportive care only. Median survival after relapse was 12 months overall: 14 months after EPP and 8 after PD, a difference that was not statistically significant (p = 0.4338). Predictors of longer survival after relapse were epithelial histology, local failure, disease-free survival of 12 months or more, and post-recurrence medical treatment. The authors concluded that the type of surgery seemed not to influence survival after relapse in patients fit enough for further treatment. They noted possible selection bias and unequal follow-up between the groups.

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-center retrospective study of patients with recurrence after multimodality treatment
• Who was studied: 94 patients with recurrent malignant pleural mesothelioma after multimodality treatment with macroscopic complete resection at Padova University Hospital, Italy, operated on between July 1994 and February 2020. They were selected from 250 surgically treated patients: 36 with incomplete resection and 2 with missing resection information were excluded, and of 175 with recurrence, 1 non-cancer death and 80 with missing data were excluded. 49 had EPP and 45 had PD; 81 had epithelial histology.
• Exposure: The article does not report asbestos or fiber exposure for these patients. What was compared was treatment: multimodality therapy including surgery by extrapleural pneumonectomy (EPP) or pleurectomy/decortication (PD), platinum-based induction and/or adjuvant chemotherapy, and in most patients adjuvant radiotherapy (dose range 40 to 50 Gy). The study also looked at the treatments given after recurrence.
• Main results:
  • Pattern of relapse in all 94 patients: local only in 27 (28.7%), distant only in 27 (28.7%), local and distant in 40 (42.6%).
  • EPP group (n = 49): relapse local in 8 (16.3%), distant in 23 (46.9%), local and distant in 18 (36.7%).
  • PD group (n = 45): relapse local in 19 (42.2%), distant in 4 (8.9%), local and distant in 22 (48.9%).
  • Of the 94 patients with recurrence, 81 (86.2%) received post-recurrence treatment and 13 (13.8%) received best supportive care only.
  • Redo surgery was performed in 13 patients (13.8%; 10 EPP, 3 PD), with no complications reported.
  • Median overall survival was 33 months for all patients: 38 months in the EPP group and 23 months in the PD group (p = 0.0199).
  • Median disease-free survival was 14 months for all patients: 20 months in the EPP group and 11 months in the PD group (p less than 0.0001).
  • Median post-recurrence survival was 12 months for all patients: 14 months in the EPP group and 8 months in the PD group.
  • The difference in post-recurrence survival between the EPP and PD groups was not statistically significant (p = 0.4338; significance threshold p less than 0.05).
  • Cox-regression predictors of better post-recurrence survival: epithelial histology (p = 0.026, HR 0.491, 95% CI 0.263 to 0.916).
  • Further predictors of better post-recurrence survival: local failure (p = 0.027, HR 0.707, 95% CI 0.521 to 0.961) and disease-free survival of 12 months or more (p = 0.006, HR 0.298, 95% CI 0.137 to 0.812). Post-recurrence medical treatment was also a predictor (p = 0.046, HR 0.101, printed 95% CI 0.897 to 0.936; see text problems).
  • Cox-regression predictors of better overall survival included EPP (p = 0.011, HR 0.524, 95% CI 0.318 to 0.863) and epithelial histology (p = 0.001, HR 0.341, 95% CI 0.182 to 0.639).
• The authors' conclusion: The authors concluded that the type of surgery (EPP vs. PD) seemed not to influence post-recurrence survival if patients were fit enough for post-recurrence treatment. They also concluded that, in patients with a prolonged disease-free interval, systemic medical therapy seemed the most appropriate treatment at recurrence, even for local-only relapse.
• Limitations the authors state:
  • The study was single-center and retrospective.
  • There was possible selection bias related to preoperative performance status in the EPP group.
  • The authors offered EPP only to fit, young patients, so important selection bias must be considered when comparing the groups.
  • Follow-up length differed between the groups: 35.6 months for EPP vs. 21.1 months for PD.
  • Only relapsed patients were included, which the authors say may bias the overall survival analysis.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Multimodal Therapy, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D), Multivariate Analysis, Histology.

Related studies

• Relapse pattern and second-line treatment following multimodality treatment for malignant pleural mesothelioma — A. Kostron, M. Friess, et al. (2016)
• Post-Recurrence Treatment Patterns and Outcomes After Curative-Intent Multimodality Strategy in Patients with Pleural Mesothelioma: A Retrospective Cohort Study — O. Illini, H. Fabikan, et al. (2026)
• Updated patterns of failure after multimodality therapy for malignant pleural mesothelioma — E.H. Baldini, W.G. Richards, et al. (2015)
• Patterns of disease progression on 18F-fluorodeoxyglucose positron emission tomography-computed tomography in patients with malignant pleural mesothelioma undergoing multimodality therapy with pleurectomy/decortication — A. Bille, S. Chicklore, et al. (2013)
• A New Prognostic Score Supporting Treatment Allocation for Multimodality Therapy for Malignant Pleural Mesothelioma: A Review of 12 Years' Experience — I. Opitz, M. Friess, et al. (2015)
• Sarcopenia as a Predictor of Short- and Long-Term Outcomes in Patients Surgically Treated for Malignant Pleural Mesothelioma — E. Faccioli, S. Terzi, et al. (2022)

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