Pleural mesothelioma: is the surgeon still there?

Abstract

Malignant pleural mesothelioma (MPM) is a rare malignancy with some unique characteristics. Tumor biology is aggressive and prognosis is poor. Despite more knowledge on histology, tumor biology and staging, there is still a relevant discrepancy between clinical and pathologic staging resulting in difficult prediction of prognosis and treatment outcome, making treatment allocation more challenging than in most other malignancies. After years of nihilism in the late 80s, a period of activism started evaluating different treatment protocols combined with research driven mainly by academic centers; at the time, selection was based on histology and stage only. This period was important to gain knowledge about the disease. However, the interpretation of data was difficult since selection criteria and definitions varied substantially. Not surprisingly, until now there is no common agreement on best treatment even among specialists. Hence, a review of our current concepts is indicated and personalized treatment should become applicable in the future. Surgery was and still is an issue of debate. In principle, surgery is an effective approach as it allows macroscopic complete elimination of a tumor, which is relatively resistant to medical treatment. It helps to set the clock back and other therapies that have also just a limited effect can be applied sequentially before or after surgery. Furthermore, to date best long-term outcome is reported from surgical series in combination with other modalities. However, part of the community considers surgery associated with too high morbidity and mortality when balanced to the limited life expectancy. This criticism is understandable, since poor results after surgery are reported. The present article will review the indication for surgery and discuss the different procedures available for macroscopic complete resection-such as lung-preserving (extended) pleurectomy/decortication as well as extrapleural pneumonectomy to illustrate that 'The surgeon is still there!'

Preoperative Identification of Benefit from Surgery for Malignant Pleural Mesothelioma

“…4) treated with the identical multimodality concept, 113 so that currently the authors are prospectively evaluating the score as an inclusion criterion for clinical trials. 112 The comparison of MMPS score with EORTC score using ROC curve analysis at 2 years showed that the MMPS demonstrated a better predictive power for OS than the EORTC score. 10,113 The recommendations from current BTS guidelines for the investigation and management of MPM 42 include the following (all grade D).…”

“…Univariate and multivariate analyses revealed that the significant independent predictors of poor survival outcomes were the nonepithelioid histologic type, increased serum LDH, an NLR of !5.0, and a TLG of !525 g. 111 The problem with most of the scores so far is the lack of validation in independent cohorts and the inclusion of clinical variables being available before surgery to help decision-making for or against surgical resection. 112 For this purpose, the authors defined in 2012 a multimodality prognostic score (MMPS) to screen patients and define subgroups eligible or especially not eligible for surgery. 113 The items in the score consisted of tumor volume before chemotherapy (>500 mL), nonepithelioid histologic subtype, CRP greater than 30 mg/L before chemotherapy, and progressive disease after chemotherapy assessed by mRE-CIST criteria.…”

When magnetic resonance imaging is needed: malignant pleural mesothelioma with transdiaphragmatic infiltration and localized appearance: a case report

“…However, the role of chemotherapy has yet to be assessed in these patients (5-7). In contrast, international guidelines are established for the initial treatment of diffuse MPM and a multimodality concept including (neo)-or adjuvant chemotherapy with platinum and anti-folate doublet, followed by macroscopic complete resection has been shown to extend the overalland disease-free survival (8)(9)(10)(11)(12)(13).…”

Editorial: Emerging Therapies for Malignant Mesothelioma

“…Although radical surgery continues to be associated with superior survival figures, it is unable to shift survival beyond the 2-year mark (6) and the reality is that <10% of patients will be judged eligible for radical multimodality therapy. Moreover, the peri-operative mortality of extra-pleural pneumonectomy turned out to be considerable, eliciting discussions about acceptable levels of surgical morbidity/mortality and the feasibility of aggressive multimodality approaches (7)(8)(9).…”