Surgery for pleural mesothelioma, when it is indicated and why: arguments against surgery for malignant pleural mesothelioma

Our plain-English summary of Surgery for pleural mesothelioma, when it is indicated and why: arguments against surgery for malignant pleural mesothelioma, by G.A. Woodard, D.M. Jablons (Translational Lung Cancer Research, 2020).

The study

• Authors: G.A. Woodard, D.M. Jablons
• Journal: Translational Lung Cancer Research
• Published: 2020;9(Suppl 1):S86-S91
• Type of article: Review
• Cited by: 18 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Extrapleural pneumonectomy (EPP) and pleurectomy decortication (PD) are radical operations for malignant pleural mesothelioma (MPM) that remain controversial among thoracic surgeons. There is a lack of randomized evidence to support a survival benefit when major surgical resection is included in multi-modality treatment regimens. Current data from retrospective single institution reviews and prospective trials such as the Surgery for Mesothelioma After Radiation Therapy (SMART) trial are limited by biased patient selection to include only the healthiest patients with most limited disease burden. This patient population predictably has relatively longer survival times than patients with inoperable advanced disease. The only randomized trial to date that has objectively evaluated the true benefit of surgical resection was the Mesothelioma and Radical Surgery (MARS) trial which actually showed shorter survival times among patients who underwent EPP compared with those treated medically. Critics of the MARS trial cite a high perioperative mortality rate for driving these results, however a similar trial has never been repeated to refute the MARS trial results. Finally, it is relevant to consider the high mortality and morbidity rates associated with major operations when recommending these interventions to MPM patients. There is a growing body of literature that identifies patients who clearly obtain no benefit from surgery including those with sarcomatoid or biphasic histology, nodal disease, elevated CRP, elevated platelets and advanced age. Surgery in MPM has risks and is of questionable benefit with outcomes data biased by patient selection of those who will have longer overall survival times regardless of treatment.

2020 Translational Lung Cancer Research. All rights reserved.

In plain English

This review article, by two authors from the Department of Surgery at the University of California, San Francisco, presented the case against major surgery for malignant pleural mesothelioma. It reported no new data. It discussed published studies of two operations: extrapleural pneumonectomy (EPP), which removes the whole lung with surrounding tissues, and pleurectomy decortication (PD), which strips the pleura but spares the lung. The authors described the MARS trial, which they called the only randomized trial to date. In that trial, median survival was 19.5 months for patients randomized to no EPP and 14.4 months for the EPP group. They argued that other studies, including the SMART trial and single-hospital series, mostly included the healthiest patients with limited disease, which biases survival results. They cited reported death rates after EPP of 5 to 7% within 30 days or in hospital. They also listed features linked to poor survival after surgery, including sarcomatoid or biphasic tumors, lymph node disease and raised CRP. The authors concluded that a randomized trial comparing non-surgical and surgical treatment is needed to justify continuing these operations.

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: Review article (narrative, presenting arguments against surgery as one side of a debate); no new data collected
• Who was studied: Published studies of surgery for malignant pleural mesothelioma, including the MARS randomized trial (12 United Kingdom hospitals, 2005 to 2008), the SMART trial, and retrospective single-institution series
• Exposure: Not an asbestos exposure study. The treatments discussed were extrapleural pneumonectomy (EPP) and pleurectomy decortication (PD), alone or as part of multi-modality treatment.
• Main results:
  • As reported from the MARS trial: median survival was 19.5 months for patients randomized to no EPP and 14.4 months for the EPP group, in an intention-to-treat analysis
  • As reported from the MARS trial: one-year survival was 52.2% in the EPP group and 73.1% in the non-EPP group, with a hazard ratio of 1.90 (P=0.082). After adjustment for prespecified prognostic risk factors, the hazard ratio for EPP was 2.75 (P=0.016).
  • As reported from the MARS trial: perioperative mortality was 16% among the 19 patients in whom EPP was attempted
  • As reported from the SMART trial: only 18% of 138 patients evaluated were eligible for the study
  • In the updated SMART approach results, the sub-group with the greatest benefit (pure epithelial histology and ypN0 disease) was 17 patients out of 256 evaluated from 2008 to 2014, and only 6 of those 17 were known to be alive 3 years after the start of treatment
  • According to the authors, median survival after EPP or PD in single-institution series is routinely cited as 14 to 18 months, which they described as essentially the same as for non-operative patients
  • Cited studies reported 30-day or in-hospital mortality after EPP of 5 to 7% even at experienced high-volume centers, and 11% when patients were followed to 90 days
  • A cited SEER database study of patients who had any type of surgical resection reported median overall survival of 19 months for epithelial histology, 12 months for biphasic histology and 4 months for pure sarcomatoid histology
  • A cited Austrian multicenter study reported median survival after surgery of 35.9 months for patients with normal CRP (below 1.0 mg/dL) versus 9.7 months for patients with CRP above 1.0 mg/dL
• The authors' conclusion: The authors concluded that there is a lack of randomized trial evidence for any survival benefit from EPP or PD. In their view, a randomized controlled trial comparing non-surgical multi-modality management with aggressive operations is needed to justify continuing these operations.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Extrapleural Pneumonectomy (EPP), Surgical Resection, Mesothelioma, Sarcomatoid, Biphasic Mesothelioma, Histology, Overall Survival.

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