New concepts in the treatment of malignant pleural mesothelioma

Abstract

Malignant pleural mesothelioma (MPM) is an aggressive solid malignancy with a median overall survival of 8 months (1). First line combination therapy of cisplatin and pemetrexed has brought an overall survival benefit of only 11 weeks compared to cisplatin alone (2,3). Despite the limited efficacy of this regimen, it has continued as standard MPM therapy 14 years after its acceptance, underscoring the urgent need for novel treatments that improve the lives of MPM patients. Within this focused review (4), Wald and Sugarbaker elaborate on novel advanced classification and prognostication methods that shine a light on the path to personalized medicine, possibly matching the right therapy with the right patient. Several key principles and evolving concepts in the care of MPM patients are discussed.As well known in MPM, surgical resection of the tumor is a major therapeutic option that is often combined with chemotherapy. A major controversy in this field has been the appropriate identification of patients that would benefit from multimodality treatments (MMT) protocol. In this review the authors also refer to known biomarkers for that aim. The tumor histology and lymph node status profoundly affect long term survival and treatment strategy for a patient with mesothelioma. As reported in several recent papers (5,6), MPM with pure epithelioid histology is associated with significantly prolonged survival. Consequently, the authors emphasize the importance of a proper and representative tissue sample for avoiding misclassification of mesothelioma subtype even with the means of more invasive procedures. In the recent work of Friedberg and colleagues long term outcomes of 73 MPM patients with histology confirmed epithelioid subtype treated with MMT protocol were demonstrated. The median overall and disease-free survival was 3 and 1.2 years, respectively (7). In addition, the authors discuss the changes in the 2016 MPM staging system which are summarized by unification of the previous T1a and T1b tumors into a new T1 category and the unification of the previous N2 lymph nodes into the N1 category based on accumulated prognostic data. In the previous staging system patients with N2 nodes were regarded as stage III with median survival of 14 months while according with the new staging system they belong to stage II group with improvement of 5 months in the median survival. In the paucity of properly established clinical trials comparing chemotherapy to surgery based MMT, we agree with the authors attitude and stress the importance of surgery based MMT protocols for mesothelioma treatment based on retrospective and prospective cohort studies. The international mesothelioma interest group viewpoint as well as the National Comprehensive Cancer Network (NCCN) highlight the important role of surgical macroscopic complete resection (MCR) and control of micro metastatic disease as part of MPM MMT protocols (8). MCR can be achieved by pleurectomy decortication (PD) or by extrapleural pneumonectomy (EPP). Specifically, the most prolo...

Update on biology and management of mesothelioma

“…Although many guidelines recommend maximal macroscopic resection for patients with early-stage mesothelioma, there is a paucity of high-quality evidence to support this. Both of these procedures are associated with significant post-operative mortality and morbidity, with some studies reporting morality rates as high as 15% when delivered as part of multimodal therapy [75].…”

Pleurectomy Decortication in the Treatment of Malignant Pleural Mesothelioma

“…5 There is general support to the notion that the best long-term results for MPM are achieved when several modalities, mainly surgery, and chemotherapy, are combined. 6,7 The international mesothelioma interest group and the National Comprehensive Cancer Network highlight the important role of surgical macroscopic complete resection (MCR) and control of micro metastatic disease as part of MPM multimodality treatment protocols. 8 MCR has been defined as removal of all grossly visible and palpable disease 9 and can be achieved by extended pleurectomy and decortication (ePDC) or by EPP.…”

The Role of Surgery in Pleural Mesothelioma

“…Studies show that the most favorable long-term results for PM are attained through the combination of several modalities, particularly when surgery and chemotherapy are combined [16,17]. Guidelines endorse the use of surgery for definitive resection with the goal of achieving macroscopic complete resection (MCR).…”