The Role of Surgery in Pleural Mesothelioma

Our plain-English summary of The Role of Surgery in Pleural Mesothelioma, by M. Lapidot, M. Sattler (Cancers, 2024).

The study

• Authors: M. Lapidot, M. Sattler
• Journal: Cancers
• Published: 2024;16(9)
• Type of article: Review
• Cited by: 7 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Surgery plays a central role in the diagnosis, staging, and management of pleural mesothelioma. Achieving an accurate diagnosis through surgical intervention and identifying the specific histologic subtype is crucial for determining the appropriate course of treatment. The histologic subtype guides decisions regarding the use of chemotherapy, immunotherapy, or multimodality treatment. The goal of surgery as part of multimodality treatment is to accomplish macroscopic complete resection with the eradication of grossly visible and palpable disease. Over the past two decades, many medical centers worldwide have shifted from performing extra-pleural pneumonectomy (EPP) to pleurectomy decortication (PD). This transition is motivated by the lower rates of short-term mortality and morbidity associated with PD and similar or even better long-term survival outcomes, compared to EPP. This review aims to outline the role of surgery in diagnosing, staging, and treating patients with pleural mesothelioma.

In plain English

This article was a review, not a new study. The authors, thoracic surgery and oncology specialists in Boston, described the role of surgery in diagnosing, staging and treating pleural mesothelioma, drawing on treatment guidelines and published studies, including their own group's earlier work. The review does not discuss asbestos exposure. It cited the group's earlier study of 147 patients found after pleurectomy decortication (PD) to have biphasic mesothelioma, of whom 60 (40.7%) had first been diagnosed as epithelioid. It reported 30-day and 90-day death rates of 3% and 4.6% in an earlier series of 355 PD patients at Brigham and Women's Hospital. It cited a systematic review of 1145 patients in which deaths around the time of surgery (2.9% versus 6.8%) and complications were lower with extended PD than with extra-pleural pneumonectomy (EPP), while overall survival was comparable. The authors advised caution about early, unpublished results of the MARS-2 trial, whose researchers concluded extended PD should not be offered. The authors concluded that surgery plays an essential role in mesothelioma care. They noted that properly established trials comparing chemotherapy with surgery-based treatment are lacking.

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 guidelines and published studies on surgery for pleural mesothelioma, written by surgeons who also describe their own institution's practice and earlier studies
• Who was studied: Published guidelines (NCCN, ESMO, ASCO, ESTS) and surgical studies of pleural mesothelioma patients, including a table of surgical series with more than 100 patients. No search method or time frame for selecting studies is described.
• Exposure: Not addressed. The review concerns surgical treatment (extra-pleural pneumonectomy, pleurectomy decortication, biopsies, palliative procedures) and does not discuss asbestos or fiber types.
• Main results:
  • In the authors' group's earlier study of 147 consecutive patients diagnosed after PD with biphasic mesothelioma, only 83 had a matching biphasic diagnosis before surgery. 60 (40.7%) had first been diagnosed as epithelioid and 4 (2.7%) as sarcomatoid.
  • In an earlier series of 355 patients who underwent PD at Brigham and Women's Hospital, death rates were 3% at 30 days and 4.6% at 90 days.
  • In the same 355-patient PD series, the group with macroscopic complete resection (MCR) had a median survival of 23.2 months and a 5-year survival of 21.2%.
  • A cited systematic review of 1145 patients found that, with extended PD compared with EPP, perioperative death (2.9% versus 6.8%, p value printed as 0.02) and complications (27.9% versus 62.0%, p less than 0.001) were significantly lower, while overall survival was comparable.
  • A cited meta-analysis compared 1512 PD patients with 1391 EPP patients and found short-term mortality 2.5-fold higher in the EPP group.
  • The MARS-1 randomized trial (50 patients randomized, 16 in the EPP arm) showed poorer survival in the EPP arm. The authors listed criticisms of the trial, including its small size and 18% surgical mortality.
  • In preliminary results of the MARS-2 trial, 335 patients were randomized to extended PD with chemotherapy or to chemotherapy alone. Its researchers concluded extended PD should not be offered. The authors noted the results were not yet peer reviewed and raised concerns about imbalance between the groups.
• The authors' conclusion: The authors concluded that surgery plays an essential role in diagnosis, staging, treatment with intent to cure, and palliation of pleural mesothelioma. They noted that, given higher mortality and morbidity with EPP, many centers, including theirs, have moved from EPP to PD.
• Limitations the authors state:
  • The authors stated that properly established clinical trials comparing chemotherapy to surgery-based multimodality treatment are lacking.
  • The authors noted that the comparisons favoring PD over EPP come from non-randomized research studies.
  • The authors stated that no published series yet address the role of immunotherapy as part of multimodality treatment.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Staging, Histological Subtype, Chemotherapy, Immunotherapy, Pneumonectomy.

Related studies

• Extra-pleural pneumonectomy versus no extra-pleural pneumonectomy for patients with malignant pleural mesothelioma: clinical outcomes of the Mesothelioma and Radical Surgery (MARS) randomised feasibility study — T. Treasure, L. Lang-Lazdunski, et al. (2011)
• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for malignant peritoneal mesothelioma: a systematic review and meta-analysis — J.H. Helm, J.T. Miura, et al. (2015)
• Phase III randomized trial of surgery with or without intraoperative photodynamic therapy and postoperative immunochemotherapy for malignant pleural mesothelioma — H.I. Pass, B.K. Temeck, et al. (1997)
• Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy — G. Glockzin, H.J. Schlitt, et al. (2009)
• Does surgery improve survival of patients with malignant pleural mesothelioma?: a multicenter retrospective analysis of 1365 consecutive patients — P. Bovolato, C. Casadio, et al. (2014)
• Value of laparoscopy before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis — L.H. Iversen, P.C. Rasmussen, et al. (2013)

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