Long term survival after trimodal therapy in malignant pleural mesothelioma
PRINCIPLES: Trimodal therapy results in long term survival in a small fraction of patients with malignant pleural mesothelioma, particularly in patients having epithelial histology, R0-resection and no nodal involvement. This study analyses the outcome after trimodal therapy including extrapleural pneumonectomy.
METHODS: From 2000 to 2005 41 patients with histologically verified malignant pleural mesothelioma were included. Diagnosis and nodal status were confirmed by surgery. 21 patients (51%) underwent trimodal therapy with 655 days (63–2,567 days) of median follow-up. Postoperative complications, mortality, long term survival and recurrence rates were analysed retrospectively.
RESULTS: Neoadjuvant chemotherapy consisted of a combination of platinum based agents (n = 19) with gemcitabine (n = 15) or pemetrexed (n = 4). Extrapleural pneumonectomy was the standard procedure for surgery. 13 patients (62%) had postoperative complications. 16 patients (76%) received postoperative adjuvant radiotherapy. There was a 30-day mortality of 4.8% in the trimodal group. Survival rates in the trimodal group were 71% after one, 28% after two and 10% after five years. There were no significant differences regarding age, tumour stage, cell type or lymph node involvement. Tumour recurrence occurred after one and two years in 44% and in 83% respectively.
CONCLUSIONS: The majority of patients considered for surgical resection of malignant pleural mesothelioma have regionally advanced disease. In those receiving trimodal therapy long term survival is achieved only in a minority of patients. In view of the time consuming and intensive treatment it should be offered only in carefully selected patients as new surgical approaches such as pleurectomy/decortication have shown high efficacy rates regarding patients’ survival.
- Pistolesi M, Rusthoven J. Malignant pleural mesothelioma: update, current management, and newer therapeutic strategies. Chest. 2004;126(4):1318–29.
- Godleski JJ. Role of asbestos in etiology of malignant pleural mesothelioma. Thorac Surg Clin. 2004;14(4):479–87.
- Mahe MA, Cellerin L, Michaud JL, Sagan C, Supiot S, Le Pechoux C. Recent progress in treatment of malignant pleural mesothelioma. Cancer Radiother. 2005;9(6–7):362–5.
- Hodgson JT, McElvenny DM, Darnton AJ, Price MJ, Peto J. The expected burden of mesothelioma mortality in Great Britain from 2002 to 2050. Br J Cancer. 2005;92(3):587–93.
- Sugarbaker DJ, Flores RM, Jaklitsch MT, Richards WG, Strauss GM, Corson JM, et al. Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: results in 183 patients. J Thorac Cardiovasc Surg. 1999;117(1):54–63; discussion 63–5.
- Stewart DJ, Martin-Ucar A, Pilling JE, Edwards JG, O’Byrne KJ, Waller DA. The effect of extent of local resection on patterns of disease progression in malignant pleural mesothelioma. Ann Thorac Surg. 2004;78(1):245–52.
- Merritt N, Blewett CJ, Miller JD, Bennett WF, Young JE, Urschel JD. Survival after conservative (palliative) management of pleural malignant mesothelioma. J Surg Oncol. 2001;78(3):171–4.
- Trousse DS, Avaro JP, D’Journo XB, Doddoli C, Astoul P, Giudicelli R, et al. Is malignant pleural mesothelioma a surgical disease? A review of 83 consecutive extra-pleural pneumonectomies. Eur J Cardiothorac Surg. 2009;36(4):759–63.
- Treasure T, Sedrakyan A. Pleural mesothelioma: little evidence, still time to do trials. Lancet. 2004;364(9440):1183–5.
- Sugarbaker DJ, Mentzer SJ, Strauss G. Extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma. Ann Thorac Surg. 1992;54(5):941–6.
- Neragi-Miandoab S. Multimodality approach in management of malignant pleural mesothelioma. Eur J Cardiothorac Surg. 2006;29(1):14–9.
- Yoshino I, Yamaguchi M, Okamoto T, Ushijima C, Fukuyama Y, Ichinose Y, et al. Multimodal treatment for resectable epithelial type malignant pleural mesothelioma. World J Surg Oncol. 2004;2:11.
- Yan TD, Boyer M, Tin MM, Wong D, Kennedy C, McLean J, et al. Extrapleural pneumonectomy for malignant pleural mesothelioma: outcomes of treatment and prognostic factors. J Thorac Cardiovasc Surg. 2009;138(3):619–24.
- van Schil PE, Baas P, Gaafar R, Maat AP, van de Pol M, Hasan B, et al. Trimodality therapy for malignant pleural mesothelioma: results from an EORTC phase II multicentre trial. Eur Resp J. 2010;36:1362–9.
- Treasure T, Lang-Lazdunski L, Waller D, Bliss JM, Tan C, Entwisle J, et al. 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. Lancet Oncol. 2011;12:763–72.
- Lang-Lazdunski L, Bille A, Lal R, Cane P, McLean E, Landau D, et al. Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma. J Thorac Oncol. 2012;7:737–43.
- Friedberg JS, Culligan MJ, Mick R, Stevenson J, Hahn SM, Sterman D, et al. Radical pleurectomy and intraoperative photodynamic therapy for malignant pleural mesothelioma. Ann Thorac Surg. 2012;93:1658–67.
- Buduhan G, Menon S, Aye R, Louie B, Mehta V, Vallieres E. Trimodality therapy for malignant pleural mesothelioma. Ann Thorac Surg. 2009;88(3):870–5; discussion 876.
- Opitz I, Kestenholz P, Lardinois D, Muller M, Rousson V, Schneiter D, et al. Incidence and management of complications after neoadjuvant chemotherapy followed by extrapleural pneumonectomy for malignant pleural mesothelioma. Eur J Cardiothorac Surg. 2006;29(4):579–84.
- Sugarbaker DJ, Jaklitsch MT, Bueno R, Richards W, Lukanich J, Mentzer SJ, et al. Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies. J Thorac Cardiovasc Surg. 2004;128(1):138–46.
- Weder W, Kestenholz P, Taverna C, Bodis S, Lardinois D, Jerman M, et al. Neoadjuvant chemotherapy followed by extrapleural pneumonectomy in malignant pleural mesothelioma. J Clin Oncol. 2004;22(17):3451–7.
- Treasure T, Waller D, Swift S, Peto J. Radical surgery for mesothelioma. BMJ. 2004;328(7434):237–8.
- Butchart EG, Ashcroft T, Barnsley WC, Holden MP. Pleuropneumonectomy in the management of diffuse malignant mesothelioma of the pleura. Experience with 29 patients. Thorax. 1976;31(1):15–24.
- Krug LM, Pass HI, Rusch VW, Kindler HL, Sugarbaker DJ, Rosenzweig KE, et al. Multicenter phase II trial of neoadjuvant pemetrexed plus cisplatin followed by extrapleural pneumonectomy and radiation for malignant pleural mesothelioma. J Clin Oncol. 2009;27(18):3007–13.
- Flores RM. Induction chemotherapy, extrapleural pneumonectomy, and radiotherapy in the treatment of malignant pleural mesothelioma: the Memorial Sloan-Kettering experience. Lung Cancer. 2005;49(Suppl 1):S71–4.
- Hasani A, Alvarez JM, Wyatt JM, Bydder S, Millward M, Byrne M, et al. Outcome for patients with malignant pleural mesothelioma referred for Trimodality therapy in Western Australia. J Thorac Oncol. 2009;4(8):1010–6.
- Flores RM, Zakowski M, Venkatraman E, Krug L, Rosenzweig K, Dycoco J, et al. Prognostic factors in the treatment of malignant pleural mesothelioma at a large tertiary referral center. J Thorac Oncol. 2007;2(10):957–65.
- de Perrot M, Uy K, Anraku M, Tsao MS, Darling G, Waddell TK, et al. Impact of lymph node metastasis on outcome after extrapleural pneumonectomy for malignant pleural mesothelioma. J Thorac Cardiovasc Surg. 2007;133(1):111–6.
- Edwards JG, Stewart DJ, Martin-Ucar A, Muller S, Richards C, Waller DA. The pattern of lymph node involvement influences outcome after extrapleural pneumonectomy for malignant mesothelioma. J Thorac Cardiovasc Surg. 2006;131(5):981–7.
- Janne PA, Baldini EH. Patterns of failure following surgical resection for malignant pleural mesothelioma. Thorac Surg Clin. 2004;14(4):567–73.
- Rice DC, Stevens CW, Correa AM, Vaporciyan AA, Tsao A, Forster KM, et al. Outcomes after extrapleural pneumonectomy and intensity-modulated radiation therapy for malignant pleural mesothelioma. Ann Thorac Surg. 2007;84(5):1685–92; discussion 1692–3.
- Flores RM. Surgical options in malignant pleural mesothelioma: extrapleural pneumonectomy or pleurectomy/decortication. Semin Thorac Cardiovasc Surg. 2009;21(2):149–53.
- Flores RM, Pass HI, Seshan VE, Dycoco J, Zakowski M, Carbone M, et al. Extrapleural pneumonectomy versus pleurectomy/decortication in the surgical management of malignant pleural mesothelioma: results in 663 patients. J Thorac Cardiovasc Surg. 2008;135(3):620–6, 6 e1–3.
- Treasure T, Waller D, Tan C, Entwisle J, O’Brien M, O’Byrne K, et al. The mesothelioma and radical surgery randomized controlled trial: the Mars feasibility study. J Thorac Oncol. 2009;4(10):1254–8.
- Greene FL, Page DL, Fleming ID, Fritz A, Balch CM, Haller DG, Morrow M (eds). AJCC Cancer Staging Manual. 6th ed. New York: Springer; 2002.