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Kuribayashi K, Doi H, Kijima T. Types of surgery post-neoadjuvant chemotherapy for pleural mesothelioma. Expert Rev Respir Med 2019; 13:1189-1194. [PMID: 31596628 DOI: 10.1080/17476348.2019.1679119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: The surgical arm of the Mesothelioma and Radical Surgery (MARS) trial involved a multimodal approach, with combined therapy consisting of chemotherapy, complete gross resection, and radiation therapy. However, the MARS trial did not compare surgery with chemotherapy, and the survival and quality of life outcomes of this trial's surgical arm were inferior to those of the non-surgical arm. Methods for achieving complete gross resection (macroscopic complete response [MCR]) include extrapleural pneumonectomy (EPP), wherein the pleura, lung, diaphragm, and pericardium are removed en bloc, and pleurectomy/decortication (P/D), wherein the affected lung is preserved. Nonetheless, the most effective therapy remains unclear.Areas covered: Here, surgery post-neoadjuvant chemotherapy for malignant pleural mesothelioma with either EPP or P/D has been discussed, along with trimodal and bimodal therapies.Expert opinion: With the development of post-P/D radiation therapy, it is currently possible to truly compare EPP with P/D. Moreover, R0 resection cannot be achieved with either EPP or P/D; thus, both must incorporate debulking, although the two procedures are largely incompatible. Therefore, there is a need to rebuild the status of surgery as a multimodal therapy.
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Affiliation(s)
- Kozo Kuribayashi
- Division of Respiratory Medicine, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroshi Doi
- Department of Radiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takashi Kijima
- Division of Respiratory Medicine, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
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2
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Limax Nd:YAG laser-assisted thoracoscopic resection of pulmonary metastases; a single centre's initial experience. Ir J Med Sci 2018; 188:771-776. [PMID: 30382512 DOI: 10.1007/s11845-018-1924-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 10/25/2018] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Pulmonary metastasectomy and indeed redo-pulmonary metastasectomy are now commonly performed thoracic surgical procedures. The air-sealant, haemostatic, and necrotic properties of the KLS Martin Limax Nd:YAG laser at 1.318 μm make it an ideal tool for limited lung resection such as metastasectomy. We present our initial experience of thoracoscopic laser metastasectomy. METHODS We reviewed data from the first seven patients in our unit to undergo thoracoscopic laser metastasectomy, in particular, patient age, gender, primary malignancy, primary treatment, complications, length of stay (LOS), and final histopathology. All procedures were performed using a two- or three-port thoracoscopic technique with some lesions requiring CT-guided wire localisation. A single drain was inserted via the camera port site and was removed upon confirmation that there was no air leak. RESULTS Seven patients underwent thoracoscopic laser wedge metastasectomy of eight lesions in our centre between February 2017 and October 2017. The median age was 61 years. The primary disease was colorectal carcinoma in five cases, eccrine carcinoma in one case, and high-grade uterine leiomyosarcoma in one case. Only one patient had a prolonged air leak in the other six cases; the drain was removed on post-operative day 1. The median post-operative LOS was 1 day. All patients had confirmed metastatic disease with clear resection margins on histopathology. CONCLUSION In our early experience, thoracoscopic laser wedge metastasectomy is a safe and efficient method for performance of pulmonary metastasectomy. We experienced a low complication rate and a short post-operative stay.
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3
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Rosskamp M, Macq G, Nackaerts K, Praet M, Van Eycken L, Van Meerbeeck JP, De Schutter H. Real-life treatment practice for malignant pleural mesothelioma in Belgium. Lung Cancer 2018; 125:258-264. [DOI: 10.1016/j.lungcan.2018.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/13/2018] [Accepted: 10/06/2018] [Indexed: 01/27/2023]
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4
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Extrapleural Pneumonectomy Is Not Shown to Be Clinically Effective in the Treatment of Malignant Pleural Mesothelioma. Ann Surg 2017; 265:e53. [PMID: 28266992 DOI: 10.1097/sla.0000000000001266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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5
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Yamauchi Y, Safi S, Orschiedt L, Gardyan A, Brons S, Rieber J, Nicolay NH, Huber PE, Eichhorn M, Dienemann H, Herth FJF, Weber KJ, Debus J, Hoffmann H, Rieken S. Low-dose photon irradiation induces invasiveness through the SDF-1α/CXCR4 pathway in malignant mesothelioma cells. Oncotarget 2017; 8:68001-68011. [PMID: 28978091 PMCID: PMC5620231 DOI: 10.18632/oncotarget.19134] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 06/10/2017] [Indexed: 11/28/2022] Open
Abstract
Background Low-dose photon irradiation has repeatedly been suspected to increase a risk of promoting local recurrence of disease or even systemic dissemination. The purpose of this study was to investigate the motility of malignant pleural mesothelioma (MPM) cell lines after low-doses of photon irradiation and to elucidate the mechanism of the detected phenotype. Methods H28 and H226 MPM cells were examined in clonogenic survival experiments and migration assays with and without various doses of photon and carbon ion irradiation. C-X-C chemokine receptor type 4 (CXCR4), SDF-1α, β1 integrin, α3 integrin, and α5 integrin expressions were analyzed by quantitative FACS analysis, ELISA and western blots. Apoptosis was assessed via Annexin-V-staining. Results The migration of MPM cells was stimulated by both fetal bovine serum and by stromal cell-derived factor 1α (SDF-1α). Low doses of photon irradiation (1 Gy and 2 Gy) suppressed clonogenicity, but promoted migration of both H28 and H226 cells through the SDF-1α/CXCR4 pathway. Hypermigration was inhibited by the administration of CXCR4 antagonist, AMD3100. In contrast, corresponding doses of carbon ion irradiation (0.3 Gy and 1 Gy) suppressed clonogenicity, but did not promote MPM cell migration. Conclusion Our findings suggest that the co-administration of photon irradiation and the CXCR4-antagonist AMD3100 or the use of carbon ions instead of photons may be possible solutions to reduce the risk of locoregional tumor recurrence after radiotherapy for MPM.
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Affiliation(s)
- Yoshikane Yamauchi
- Department of Thoracic Surgery, Thorax Clinic, Heidelberg University, Heidelberg, Germany
| | - Seyer Safi
- Department of Thoracic Surgery, Thorax Clinic, Heidelberg University, Heidelberg, Germany
| | - Lena Orschiedt
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Adriane Gardyan
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Molecular and Radiation Oncology, German Cancer Research Center (dkfz), Heidelberg, Germany
| | - Stephan Brons
- Heidelberg Ion Treatment Facility (HIT), Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Juliane Rieber
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany.,Heidelberg Ion Treatment Facility (HIT), Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany.,Heidelberg Ion Treatment Facility (HIT), Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Molecular and Radiation Oncology, German Cancer Research Center (dkfz), Heidelberg, Germany
| | - Peter E Huber
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Molecular and Radiation Oncology, German Cancer Research Center (dkfz), Heidelberg, Germany
| | - Martin Eichhorn
- Department of Thoracic Surgery, Thorax Clinic, Heidelberg University, Heidelberg, Germany
| | - Hendrik Dienemann
- Department of Thoracic Surgery, Thorax Clinic, Heidelberg University, Heidelberg, Germany
| | - Felix J F Herth
- Pneumology and Critical Care Medicine, Thorax Clinic, Heidelberg University, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRCH), Heidelberg, Germany, Member of the German Center for Lung Research (DZL)
| | - Klaus-Josef Weber
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany.,Heidelberg Ion Treatment Facility (HIT), Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany.,Heidelberg Ion Treatment Facility (HIT), Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Hans Hoffmann
- Department of Thoracic Surgery, Thorax Clinic, Heidelberg University, Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany.,Heidelberg Ion Treatment Facility (HIT), Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
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Cornelissen R, Hegmans JPJJ, Maat APWM, Kaijen-Lambers MEH, Bezemer K, Hendriks RW, Hoogsteden HC, Aerts JGJV. Extended Tumor Control after Dendritic Cell Vaccination with Low-Dose Cyclophosphamide as Adjuvant Treatment in Patients with Malignant Pleural Mesothelioma. Am J Respir Crit Care Med 2017; 193:1023-31. [PMID: 26652184 DOI: 10.1164/rccm.201508-1573oc] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE We demonstrated previously that autologous tumor lysate-pulsed dendritic cell-based immunotherapy in patients with malignant pleural mesothelioma is feasible, well-tolerated, and capable of inducing immunologic responses against tumor cells. In our murine model, we found that reduction of regulatory T cells with metronomic cyclophosphamide increased the efficacy of immunotherapy. OBJECTIVES To assess the decrease in number of peripheral blood regulatory T cells during combination therapy of low-dose cyclophosphamide and dendritic cell immunotherapy and determine the induction of immunologic responses with this treatment in patients with mesothelioma. METHODS Ten patients with malignant pleural mesothelioma received metronomic cyclophosphamide and dendritic cell-based immunotherapy. During the treatment, peripheral blood mononuclear cells were analyzed for regulatory T cells and immunologic responses. MEASUREMENTS AND MAIN RESULTS Administration of dendritic cells pulsed with autologous tumor lysate combined with cyclophosphamide in patients with mesothelioma was safe, the only side effect being moderate fever. Dendritic cell vaccination combined with cyclophosphamide resulted in radiographic disease control in 8 of the 10 patients. Overall survival was promising, with 7 out of 10 patients having a survival of greater than or equal to 24 months and two patients still alive after 50 and 66 months. Low-dose cyclophosphamide reduced the percentage of regulatory T cells of total CD4 cells in peripheral blood from 9.43 (range, 4.34-26.10) to 4.51 (range, 0.27-10.30) after 7 days of cyclophosphamide treatment (P = 0.02). CONCLUSIONS Consolidation therapy with autologous tumor lysate-pulsed dendritic cell-based therapy and simultaneously reducing the tumor-induced immune suppression is well-tolerated and shows signs of clinical activity in patients with mesothelioma. Clinical trial registered with www.clinicaltrials.gov (NCT 01241682).
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Affiliation(s)
| | | | - Alexander P W M Maat
- 2 Department of Cardio-Thoracic Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; and
| | | | | | | | | | - Joachim G J V Aerts
- 1 Department of Pulmonary Medicine and.,3 Department of Pulmonary Medicine, Amphia Hospital, Breda, the Netherlands
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Mokhles S, Takkenberg JJM, Treasure T. Evidence-Based and Personalized Medicine. It’s [AND] not [OR]. Ann Thorac Surg 2017; 103:351-360. [DOI: 10.1016/j.athoracsur.2016.08.100] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/24/2016] [Accepted: 08/25/2016] [Indexed: 10/20/2022]
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Åberg T, Treasure T. Analysis of pulmonary metastasis as an indication for operation: an evidence-based approach. Eur J Cardiothorac Surg 2016; 50:792-798. [PMID: 27369120 DOI: 10.1093/ejcts/ezw140] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
- Torkel Åberg
- Clinical Operational Research Unit, University College, London, UK
| | - Tom Treasure
- Clinical Operational Research Unit, University College, London, UK
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9
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What is the best approach for surgery of malignant pleural mesothelioma? It is to put our efforts into obtaining trustworthy evidence for practice. J Thorac Cardiovasc Surg 2016; 151:307-9. [DOI: 10.1016/j.jtcvs.2015.09.086] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/22/2015] [Indexed: 11/21/2022]
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10
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Cardillo G, Mokhles S, Williams N, Macbeth F, Russell C, Treasure T. Comment on: 'KRAS and BRAF mutations are prognostic biomarkers in patients undergoing lung metastasectomy of colorectal cancer.' Variation in survival associated with proto-oncongenes is not evidence for effectiveness of lung metastasectomy. Br J Cancer 2015; 113:1636. [PMID: 26372699 PMCID: PMC4705879 DOI: 10.1038/bjc.2015.331] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Giuseppe Cardillo
- Carlo Forlanini Hospital, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Sahar Mokhles
- Erasmus University Medical Center, Postbus 2040 3000 CA, Rotterdam, The Netherlands
| | - Norman Williams
- Clinical Trials Group, Division of Surgery & Interventional Science, Faculty of Medical Sciences, University College London, Room 4.24, 132 Hampstead Road, London NW1 2BX, UK
| | - Fergus Macbeth
- Wales Cancer Trials Unit, 6th Floor, Neuadd Meirionnydd, University Hospital of Wales, Heath Park, Cardiff CF14 4YS, UK
| | - Christopher Russell
- Division of Surgery & Interventional Science, Faculty of Medical Sciences, University College London, Room 4.24, 132 Hampstead Road, London NW1 2BX, UK
| | - Tom Treasure
- Clinical Operational Research Unit, University College London, 4 Taviton Street, London WC1H 0BT, UK
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11
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Rintoul RC, Treasure T, Macbeth F. Multimodal treatment for malignant pleural mesothelioma. Lancet Oncol 2015; 16:1576-7. [PMID: 26538424 DOI: 10.1016/s1470-2045(15)00253-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 08/17/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Robert C Rintoul
- Department of Thoracic Oncology, Papworth Hospital, Cambridge, UK
| | - Tom Treasure
- Clinical Operational Research Unit, University College London, London, UK.
| | - Fergus Macbeth
- Wales Cancer Trials Unit, University of Cardiff, Cardiff, UK
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12
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de Perrot M, Feld R, Leighl NB, Hope A, Waddell TK, Keshavjee S, Cho BCJ. Accelerated hemithoracic radiation followed by extrapleural pneumonectomy for malignant pleural mesothelioma. J Thorac Cardiovasc Surg 2015; 151:468-73. [PMID: 26614413 DOI: 10.1016/j.jtcvs.2015.09.129] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 08/24/2015] [Accepted: 09/13/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate a new protocol of accelerated hemithoracic intensity-modulated radiation therapy (IMRT) followed by extrapleural pneumonectomy (EPP) for patients with resectable malignant pleural mesothelioma (MPM). METHODS A total of 25 Gy of radiation was delivered in 5 daily fractions over 1 week to the entire ipsilateral hemithorax with concomitant boost of 5 Gy to volumes at high risk based on computed tomography and positron emission tomography scan findings. EPP was performed at 6 ± 2 days after the end of radiation therapy. Adjuvant chemotherapy was offered to patients with ypN2 disease. RESULTS A total of 62 patients were included between November 2008 and October 2014. One patient died in the hospital 2 months after EPP, for an operative mortality of 1.6%, and 2 died after discharged from the hospital for an overall treatment-related mortality (grade 5 toxicity) of 4.8%. Twenty-four patients (39%) developed grade 3 to 5 (grade 3+) complications. On final pathology, 94% of the patients were stage III or IV, and 52% had ypN2 disease. The median survival for all patients as an intention-to-treat analysis was 36 months. The median overall survival and disease-free survival was 51 and 47 months, respectively, in epithelial subtypes, compared with 10 and 8 months in biphasic subtypes (P = .001). Ipsilateral chest recurrence occurred in 8 patients. CONCLUSIONS Accelerated hemithoracic IMRT followed by EPP has become our preferred approach for resectable MPM. The results have been encouraging in patients with epithelial subtype.
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Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Princess Margaret Cancer Centre and Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
| | - Ronald Feld
- Division of Medical Oncology, Princess Margaret Cancer Centre and Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Natasha B Leighl
- Division of Medical Oncology, Princess Margaret Cancer Centre and Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Hope
- Department of Radiation Oncology, Princess Margaret Cancer Centre and Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Division of Thoracic Surgery, Princess Margaret Cancer Centre and Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Division of Thoracic Surgery, Princess Margaret Cancer Centre and Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - B C John Cho
- Department of Radiation Oncology, Princess Margaret Cancer Centre and Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Treasure T, Macbeth F, Russell C. If no difference in effectiveness is found between two treatments it may be because the treatments are similarly ineffective. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:201. [PMID: 26417585 PMCID: PMC4560711 DOI: 10.3978/j.issn.2305-5839.2015.08.05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 08/05/2015] [Indexed: 11/14/2022]
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14
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High readmission rate after heart valve surgery: A nationwide cohort study. Int J Cardiol 2015; 189:96-104. [DOI: 10.1016/j.ijcard.2015.04.078] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 04/08/2015] [Accepted: 04/10/2015] [Indexed: 11/23/2022]
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Treasure T, Milošević M, Fiorentino F, Pfannschmidt J. History and present status of pulmonary metastasectomy in colorectal cancer. World J Gastroenterol 2014; 20:14517-26. [PMID: 25356017 PMCID: PMC4209520 DOI: 10.3748/wjg.v20.i40.14517] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 07/22/2014] [Accepted: 09/12/2014] [Indexed: 02/06/2023] Open
Abstract
Clinical practice with respect to metastatic colorectal cancer differs from the other two most common cancers, breast and lung, in that routine surveillance is recommended with the specific intent of detecting liver and lung metastases and undertaking liver and lung resections for their removal. We trace the history of this approach to colorectal cancer by reviewing evidence for effectiveness from the 1950s to the present day. Our sources included published citation network analyses, the documented proposal for randomised trials, large systematic reviews, and meta-analysis of observational studies. The present consensus position has been adopted on the basis of a large number of observational studies but the randomised trials proposed in the 1980s and 1990s were either not done, or having been done, were not reported. Clinical opinion is the mainstay of current practice but in the absence of randomised trials there remains a possibility of selection bias. Randomised controlled trials (RCTs) are now routine before adoption of a new practice but RCTs are harder to run in evaluation of already established practice. One such trial is recruiting and shows that controlled trial are possible.
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Fifteen years in the evaluation of extrapleural pneumonectomy: Lessons to be learned. J Thorac Cardiovasc Surg 2014; 149:1382-3. [PMID: 25466860 DOI: 10.1016/j.jtcvs.2014.10.083] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 10/18/2014] [Indexed: 01/01/2023]
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Treasure T, Dusmet M, Fiorentino F, Lim E, Waller D, Lees B. Surgery for malignant pleural mesothelioma: why we need controlled trials. Eur J Cardiothorac Surg 2014; 45:591-2. [DOI: 10.1093/ejcts/ezu001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Treasure T, Milošević M, Fiorentino F, Macbeth F. Pulmonary metastasectomy: what is the practice and where is the evidence for effectiveness? Thorax 2014; 69:946-9. [PMID: 24415715 PMCID: PMC4174129 DOI: 10.1136/thoraxjnl-2013-204528] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pulmonary metastasectomy is a commonly performed operation and is tending to increase as part of a concept of personalised treatment for advanced cancer. There have been no randomised trials; belief in effectiveness of metastasectomy is based on registry data and surgical follow-up studies. These retrospective series are comprised predominately of solitary or few metastases with primary resection to metastasectomy intervals longer than 2-3 years. Five-year survival rates of 30-50% are recorded, but as case selection is based on favourable prognostic features, an apparent association between metastasectomy and survival cannot be interpreted as causation. Cancers for which lung metastasectomy is used are considered in four pathological groups. In non-seminomatous germ cell tumour, for which chemotherapy is highly effective, excision of residual pulmonary disease guides future treatment and in particular allows an informed decisions as to further chemotherapy. Sarcoma metastasises predominately to lung and pulmonary metastasectomy for both bone and soft tissues sarcoma is routinely considered as a treatment option but without randomised data. The commonest circumstance for lung and liver metastasectomy is colorectal cancer. Repeated resections and ablations are commonplace but without evidence of effectiveness for either. For melanoma, results are particularly poor, but lung metastases are resected when no other treatment options are available. In this review, the available evidence is considered and the conclusion reached is that in the absence of randomised trials there is uncertainty about effectiveness. A randomised controlled trial, Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC), is in progress and randomised trials in sarcoma seem warranted.
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Affiliation(s)
- Tom Treasure
- Clinical Operational Research Unit, University College London, London, UK
| | - Mišel Milošević
- Clinic for Thoracic Surgery, Institute for Pulmonary Diseases of Vojvodina, University of Novi Sad, Novi Sad, Serbia
| | - Francesca Fiorentino
- Department of Cardiothoracic Surgery, National Heart and Lung Institute, Imperial College London, London, UK
| | - Fergus Macbeth
- Wales Cancer Trials Unit, Cardiff University, Cardiff, UK
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Treasure T. Pulmonary Metastasectomy for Colorectal Cancer: Recent Reports Prompt a Review of the Available Evidence. CURRENT COLORECTAL CANCER REPORTS 2014; 10:296-302. [PMID: 25191154 PMCID: PMC4149747 DOI: 10.1007/s11888-014-0234-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pulmonary metastasectomy for colorectal cancer is commonplace surgery, but the practice has grown on the basis of follow-up studies. These studies base their conclusion on the effectiveness of metastasectomy on the survival rates at 5 years of very highly selected patients. Three publications in the last year, a registry study, a meta-analysis and a randomised controlled trial of monitoring and early detection of cancer recurrence, prompted a review of the evidence. A critical examination of the evidence suggests that much of the apparent benefit may be due to selection of patients most likely to survive on the basis of well-known prognostic features, explicitly stated in the clinical record. Clinicians also assess their patients over time and do not offer surgery to those with faster progression. Such clinical judgements are of their nature often subtle and undocumented and thus cannot be retrieved from the clinical record. Although some patients may have long survival following pulmonary metastasectomy, and indeed their survival might be believed to be due to resection of pulmonary metastases, how many patients must be operated on to find these survivors? What is the number 'needed to treat'? It may be that of the patients having metastasectomy, for the greater proportion it does not materially alter their survival. A randomised controlled trial to resolve this uncertainty is in progress. The Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC) trial is recruiting in Britain and Europe.
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Affiliation(s)
- Tom Treasure
- Clinical Operational Research Unit, University College London, London, WC1H 0BT UK
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Abstract
The role of surgery in the management of malignant pleural mesothelioma remains controversial. Surgical resection consists of different procedures for diagnostic or therapeutic reasons. The latter includes either an extrapleural pleuropneumonectomy (EPP) or lung-sparing operations like debulking of the parietal and visceral pleura by pleurectomy/decortication (P/D) or extended pleurectomy/decortication, in which further debulking of the diaphragm or pericardium is included. Because of the modest outcome of surgery as single-modality therapy, combinations of chemotherapy, surgery, and radiation therapy were initiated as a new treatment strategy to improve prognosis. The observations that patients treated with P/D had an equal to better outcome than those treated with EPP, and that EPP with perioperative chemotherapy was better than EPP alone, raises the issue whether performing a P/D with perioperative chemotherapy would result in a further improvement of outcome with a lower operative mortality than with EPP and perioperative chemotherapy. This is the rationale for the next European Organisation for Research and Treatment of Cancer trial exploring the feasibility of P/D with perioperative chemotherapy.
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Treasure T, Leonard P. Pulmonary metastasectomy in colorectal cancer. Br J Surg 2013; 100:1403-4. [PMID: 24037557 DOI: 10.1002/bjs.9174] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2013] [Indexed: 12/27/2022]
Abstract
Surgeons need to do difficult trials
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Affiliation(s)
- T Treasure
- Clinical Operational Research Unit, University College London, 4 Taviton Street, London WC1H 0BT, UK.
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Treasure T, Møller H, Fiorentino F, Utley M. Forty years on: pulmonary metastasectomy for sarcoma. Eur J Cardiothorac Surg 2013; 43:799-800. [PMID: 23509342 DOI: 10.1093/ejcts/ezs448] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Cao C, Tian D, Manganas C, Matthews P, Yan TD. Systematic review of trimodality therapy for patients with malignant pleural mesothelioma. Ann Cardiothorac Surg 2013; 1:428-37. [PMID: 23977533 DOI: 10.3978/j.issn.2225-319x.2012.11.07] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 11/15/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Malignant pleural mesothelioma (MPM) is an aggressive form of cancer arising from the pleural mesothelium. Trimodality therapy (TMT) involving extrapleural pneumonectomy with neoadjuvant or adjuvant chemotherapy and adjuvant radiotherapy is a recognized treatment option with a curative intent. Despite encouraging results from institutional studies, TMT in the treatment of MPM remains controversial. The present systematic review aims to assess the safety and efficacy of TMT in the current literature. METHODS A systematic review was performed using five electronic databases from 1 January 1985 to 1 October 2012. Studies were selected independently by two reviewers according to predefined selection criteria. The primary endpoint was overall survival. Secondary endpoints included disease-free survival, disease recurrence, perioperative morbidity and length of stay. RESULTS Sixteen studies were included for quantitative assessment, including one randomized controlled trial and five prospective series. Median overall survival ranged from 12.8-46.9 months. Disease-free survival ranged from 10-16.3 months. Perioperative mortality ranged from 0-12.5%. Overall perioperative morbidity ranged from 50-82.6% and the average length of stay was 9-14 days. CONCLUSIONS Outcomes of patients who underwent TMT in the current literature appeared to be inconsistent. Four prospective series involving a standardised treatment regimen with neoadjuvant chemotherapy indicated encouraging results based on intention-to-treat analysis. However, a small study assessing the feasibility of conducting a randomized controlled trial for TMT versus conservative treatment reported poor short- and long-term outcomes for patients who underwent pneumonectomy. Overall, results of the present systematic review suggest TMT may offer acceptable perioperative outcomes and long-term survival in selected patients treated in specialized centers.
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Affiliation(s)
- Christopher Cao
- The Systematic Review Unit, Collaborative Research (CORE) Group, Sydney, Australia; ; Department of Cardiothoracic Surgery, St George Hospital, Sydney, Australia; ; The Baird Institute for Applied Heart and Lung Surgical Research, Sydney, Australia
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Datta A, Smith R, Fiorentino F, Treasure T. Surgery in the treatment of malignant pleural mesothelioma: recruitment into trials should be the default position. Thorax 2013; 69:194-7. [PMID: 23760546 PMCID: PMC3913121 DOI: 10.1136/thoraxjnl-2013-203846] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Europe is at the peak of an epidemic of malignant pleural mesothelioma and the burden of disease is likely to continue rising in the large areas of the world where asbestos remains unregulated. Patients with mesothelioma present with thoracic symptoms and radiological changes so respiratory physicians take a leading role in diagnosis and management. Belief that the modest survival times reported after radical surgery, whether alone or as part of multimodal therapy, are longer than they it would have been without surgery relies on data from highly selected, uncontrolled, retrospectively analysed case series. The only randomised study, the Mesothelioma and Radical Surgery (MARS) trial showed no benefit. A simple modelling study of registry patients, described here, shows that an impression of longer survival is eroded when patients who were never candidates for operation on grounds of histology, performance status and age are sequentially excluded from the model. CONCLUSION Whenever the question arises `Might an operation help me?' there are two responses that can and should be given. The first is that there is doubt about whether there is any survival or symptomatic benefit from surgery but we know that there is harm. The second is that there are on-going studies, including two randomised trials, which patients should be informed about. The authors suggest that the default position for clinicians should be to encourage recruitment into these trials.
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Affiliation(s)
- Avijit Datta
- Department of Respiratory Medicine, York Teaching Hospital NHS Foundation Trust, York, UK
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Grünhagen D, Jones RP, Treasure T, Vasilakis C, Poston GJ. The history of adoption of hepatic resection for metastatic colorectal cancer: 1984-95. Crit Rev Oncol Hematol 2012. [PMID: 23199763 DOI: 10.1016/j.critrevonc.2012.10.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Liver resection for metastatic colorectal cancer became established without randomized trials. Proponents of surgical resection point out 5-year survival approaching 50% whilst critics question how much of the apparent effect is due to patient selection. METHOD A 2006 systematic review of reported outcomes provided the starting point for citation analysis followed by thematic analysis of the texts of the most cited papers. RESULTS 54 reports from 1988 to 2002 cited 709 unique publications a total of 1714 times. The 15 most cited papers were explored in detail, and showed clear examples of duplicate reporting and overlapping data sets. Textual analysis revealed proposals for a randomized controlled trial, but this was argued to be unethical by others, and no trial was undertaken. CONCLUSIONS This critical review reveals how the case for this surgery was made, and examines the arguments that influenced acceptance and adoption of this surgery.
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Affiliation(s)
- D Grünhagen
- Department of Surgery, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
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Russell RCG, Treasure T. Counting the cost of cancer surgery for advanced and metastatic disease. Br J Surg 2012; 99:449-50. [PMID: 22318744 DOI: 10.1002/bjs.8695] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2012] [Indexed: 11/11/2022]
Abstract
Putting cancer surgery into context is vital
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Affiliation(s)
- R C G Russell
- Clinical Operational Research Unit, University College London, 4 Taviton Street, London WC1H 0BT, UK
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Treasure T, Crowe S, Chan KMJ, Ranasinghe A, Attia R, Lees B, Utley M, Golesworthy T, Pepper J. A method for early evaluation of a recently introduced technology by deriving a comparative group from existing clinical data: a case study in external support of the Marfan aortic root. BMJ Open 2012; 2:e000725. [PMID: 22389361 PMCID: PMC3293136 DOI: 10.1136/bmjopen-2011-000725] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE During the early phase of evaluation of a new intervention, data exist for present practice. The authors propose a method of constructing a fair comparator group using these data. In this case study, the authors use the example of external aortic root support, a novel alternative to aortic root replacement. DESIGN A matched comparison group, of similar age, aortic size and aortic valve function to those having the novel intervention, was constructed, by minimization, from among patients having conventional aortic root replacement in other hospitals during the same time frame. SETTING Three cardiac surgical units in England. PATIENTS The first 20 patients, aged 16-58 years with aortic root diameters of 40-54 mm, having external support surgery were compared with 20 patients, aged 18-63 years and aortic root diameters of 38-58 mm, who had conventional aortic root replacement, between May 2004 and December 2009. INTERVENTIONS A pliant external mesh sleeve, customised by computer-aided design, encloses the whole of the ascending aorta. The comparator group had conventional aortic root replacement, 16 valve-sparing and four with composite valved grafts. MAIN OUTCOME MEASURES Duration of cardiopulmonary bypass (CPB), myocardial ischaemic time, blood loss and transfusion of blood, platelets and clotting factors. RESULTS Comparing total root replacement and customised aortic root support surgery: CPB (median (range)) was 134 (52-316) versus 0 (0-20) min; myocardial ischaemia 114 (41-250) versus 0 (0-0) min; 4 h blood loss was 218 (85-735) versus 50 (25-400) ml; and 9/18 had blood transfusion, 9/18 platelets and 12/18 fresh frozen plasma after root replacement versus 1/20, 0/20 and 0/20, respectively, for the novel surgery. CONCLUSIONS Avoidance or large reductions in CPB, myocardial ischaemia and blood product usage were achieved with the novel surgery. These data are of use in decision analysis and health economic evaluation and are available early in evaluation before randomised trial data are available.
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Affiliation(s)
- Tom Treasure
- Clinical Operational Research Unit, University College London, London, UK
| | - Sonya Crowe
- Clinical Operational Research Unit, University College London, London, UK
| | - K M John Chan
- The Cardiovascular Biomedical Research Unit (BRU), Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Aaron Ranasinghe
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
- Department of Cardiac Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rizwan Attia
- Department of Cardiac Surgery, Guys and St Thomas' Hospital, London, UK
| | - Belinda Lees
- The Cardiovascular Biomedical Research Unit (BRU), Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | | | - John Pepper
- The Cardiovascular Biomedical Research Unit (BRU), Royal Brompton and Harefield NHS Foundation Trust, London, UK
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Bliss JM, Coombes G, Darlison L, Edwards J, Entwisle J, Kilburn LS, Landau D, Lang-Lazdunski L, O'Brien M, O'Byrne K, Peto J, Senan S, Snee M, Spicer J, Tan C, Thomas G, Treasure T, Waller D. The MARS feasibility trial: conclusions not supported by data – Authors' reply. Lancet Oncol 2011. [DOI: 10.1016/s1470-2045(11)70308-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Treasure T, Farewell V. Minimization in interventional trials: great value but residual vulnerability. J Clin Epidemiol 2011; 65:7-9. [PMID: 21995972 DOI: 10.1016/j.jclinepi.2011.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 07/20/2011] [Indexed: 11/29/2022]
Affiliation(s)
- Tom Treasure
- Clinical Operational Research Unit, UCL (Department of Mathematics), 4 Taviton Street, London WC1H 0BT, UK.
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Malignant pleural mesothelioma: The standard of care and challenges for future management. Crit Rev Oncol Hematol 2011; 78:92-111. [DOI: 10.1016/j.critrevonc.2010.04.004] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2009] [Revised: 03/24/2010] [Accepted: 04/09/2010] [Indexed: 11/20/2022] Open
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Hasegawa S, Tanaka F, Okada M, Yamanaka T, Kamikonya N, Soejima T, Tsujimura T, Fukuoka K, Nakano T. [Current status and future direction of Japan's clinical trial for malignant pleural mesothelioma]. Nihon Eiseigaku Zasshi 2011; 66:558-561. [PMID: 21701087 DOI: 10.1265/jjh.66.558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The feasibility and efficacy of trimodality therapy for malignant pleural mesothelioma (MPM) are still controversial mainly due to the lack of clinical evidence. Although three major clinical trials on this therapy have been recently reported from North America and Europe, it remains unclear whether results in Caucasian populations may be directly applicable to Asian populations. In this context, as a project of the "Comprehensive approach on asbestos-related diseases" supported by the "Special Coordination Fund for Promoting Science and Technology of MEXT, Japan", a prospective multi-institutional study has been planned to evaluate the feasibility of induction chemotherapy using pemetrexed plus cisplatin, followed by extrapleural pneumonectomy (EPP) and postoperative hemithoracic radiation in patients with resectable MPM. Primary endpoints are macroscopic complete resection rate by EPP and treatment-related mortality for trimodality therapy. The study was initiated in May 2008 and patient enrollment was finished in November 2010.
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Affiliation(s)
- Seiki Hasegawa
- Department of Thoracic Surgery, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Japan.
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Cao C, Yan TD, Bannon PG, McCaughan BC. Summary of prognostic factors and patient selection for extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma. Ann Surg Oncol 2011; 18:2973-9. [PMID: 21512863 DOI: 10.1245/s10434-011-1728-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Extrapleural pneumonectomy (EPP) has been shown to improve long-term survival outcomes in selected patients with malignant pleural mesothelioma (MPM). The present study aimed to evaluate potential prognostic factors on overall survival for patients who underwent EPP for MPM and to examine the patient selection process in major referral centers that perform EPP. METHODS A systematic review of the current literature was performed using 5 electronic databases. Relevant studies with prognostic data on overall survival for patients with MPM treated by EPP were included for review. Two reviewers independently assessed each included study. RESULTS A total of 17 studies from 13 institutions containing the most updated and complete data on prognostic factors for patients with MPM who underwent EPP were included for review. A number of quantitative, clinical, and treatment-related factors were identified to have significant impact on overall survival. CONCLUSIONS Patients with nonepithelial MPM and nodal involvement have consistently demonstrated to have a worse prognosis after EPP. Their eligibility as candidates for EPP should be questioned. The preoperative patient selection process currently differs greatly between institutions and should focus on identifying patients with nonepithelial histologic subtypes and nodal involvement to exclude them as EPP surgical candidates in the future.
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Affiliation(s)
- Christopher Cao
- The Systematic Review Group, The Baird Institute for Applied Heart and Lung Surgical Research, Sydney, Australia
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Abstract
INTRODUCTION The primary objective of the present systematic review was to evaluate the safety and efficacy of extrapleural pneumonectomy (EPP) for patients with malignant pleural mesothelioma. METHODS A systematic review of relevant studies identified through five online search databases was performed. Two reviewers independently appraised each study. RESULTS Thirty-four of 58 relevant studies from 26 institutions containing the most updated data were evaluated for survival and perioperative outcomes after EPP. The median overall survival varied from 9.4 to 27.5 months, and 1-, 2-, and 5-year survival rates ranged from 36 to 83%, 5 to 59%, and 0 to 24%, respectively. Overall perioperative mortality rates ranged from 0 to 11.8%, and the perioperative morbidity rates ranged from 22 to 82%. Quality of life assessments from three studies reported improvements in nearly all domains at 3 months postoperatively. Patients who underwent trimodality therapy involving EPP and adjuvant chemoradiotherapy had a median overall survival of 13 to 23.9 months. DISCUSSIONS The current evidence suggests that selected patients with malignant pleural mesothelioma may benefit from EPP, especially when combined with neoadjuvant or adjuvant chemotherapy and adjuvant radiotherapy.
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Frequency of use and predictors of cancer-directed surgery in the management of malignant pleural mesothelioma in a community-based (Surveillance, Epidemiology, and End Results [SEER]) population. J Thorac Oncol 2011; 5:1649-54. [PMID: 20871264 DOI: 10.1097/jto.0b013e3181f1903e] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Surgical intervention rates for mesothelioma patients treated at specialized tertiary hospitals are well more than 42%. Mesothelioma surgical strategies in the community are less well defined. This study evaluates the frequency of use and predictors of cancer-directed surgical intervention in a nontertiary-based population and the predictors for surgical intervention. METHODS The Surveillance, Epidemiology, and End Results database was searched from 1990 to 2004. Variables analyzed included age, sex, race, year of diagnosis, region, vital status, stage, surgery, and reasons for no surgery. The association of patient variables on receipt of cancer-directed surgery was evaluated using χ(2) tests and logistic regression. The incidence of mesothelioma was also evaluated over this period of time. RESULTS Pathologically proven malignant pleural mesothelioma was identified in 1166 women and 4771 men. The rate of cancer-directed surgery was 22% (n = 1317). Significant predictors of receiving cancer-directed surgery included race, age, and stage (all p < 0.0001). A landmark analysis on the effect of cancer-directed surgery on survival after adjusting for patient and disease characteristics demonstrated a hazard ratio of 0.68 (p < 0.0001). The incidence rate of malignant pleural mesothelioma has remained constant. CONCLUSIONS The rate of surgical intervention in the community is lower compared with tertiary referral centers. Age, stage, and race predict the likelihood of receiving cancer-directed surgery. A lower rate of cancer-directed surgery and worse overall outcome were observed in black patients. As part of quality assurance, referral of patients to centers with multidisciplinary programs that include thoracic surgical expertise should be considered.
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Teh E, Fiorentino F, Tan C, Treasure T. A systematic review of lung-sparing extirpative surgery for pleural mesothelioma. J R Soc Med 2011; 104:69-80. [PMID: 21282797 PMCID: PMC3031645 DOI: 10.1258/jrsm.2010.100345] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES There is a resurgence of interest in lung-sparing extirpative surgery for malignant pleural mesothelioma with recent reports of better survival and fewer adverse consequences than with extrapleural pneumonectomy. However, these operations are not well-characterized and to offer evidence-based clinical recommendations and to plan future trials a summary of what is already known is required. DESIGN A formal literature search was performed and all recovered titles were sequentially sifted by title, abstract and full-text reading according to prespecified criteria. Papers were selected if they contained data relevant to the area of enquiry. Quantitative synthesis and textual analysis, appropriate to the material, were performed. SETTING Follow-up studies of patients undergoing surgery for malignant pleural mesothelioma in specialist thoracic or cardiothoracic units. PARTICIPANTS Among the operated patients described in these papers, a total of 1270 patients had undergone lung-sparing surgery for mesothelioma. RESULTS There were no randomized trials or other forms of controlled studies. From 464 titles, 26 papers contained sufficient data on 1270 patients to be included in the systematic review. Operative descriptions for all series were extracted and tabulated and variation was found in the nature of surgery within and between series, and the degree of detail with which it was described. There was more operative detail in recent papers. All available numerical data were extracted, tabulated and summarized using quantitative methods. The average survival at 1, 2, 3, 4 and 5 years was 51%, 26%, 16%, 11% and 9%, respectively. There were no data on patients' performance status, symptomatic change, or other patient reported outcomes. CONCLUSIONS In the absence of any form of control data, no conclusions can be drawn concerning survival differences or symptomatic benefits attributable to surgery. As mesothelioma surgery is restricted to a selected minority of patients who often have multiple therapies, future research will require controlled studies with explicit definitions of the clinical and surgical intent.
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Affiliation(s)
- Elaine Teh
- The Rayne Institute (King's College London), St Thomas' HospitalWestminster Bridge Road, London SE1 7EH, UK
| | | | | | - Tom Treasure
- Clinical Operational Research Unit, University College LondonUK
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Abstract
In March 2010, a randomized trial called Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC) was launched and is open to recruitment. The evidence for pulmonary metastasectomy reviewed in this supplement includes no randomized trials. Claims for a survival benefit for patients undergoing this surgery rely on case series. Furthermore, there is little documentation of any symptoms attributable to pulmonary metastases that are alleviated or obviated by metastasectomy. The PulMiCC study aims are to examine whether or not surgical resection of pulmonary metastases from colorectal cancer lengthens survival and to record systematically the harms and benefits of such surgery and quality of life.
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Alvarez JM, Hasani A, Segal A, Sterret G, Millward M, Nowak A, Musk W, Bydder S. Bilateral thoracoscopy, mediastinoscopy and laparoscopy, in addition to CT, MRI and PET imaging, are essential to correctly stage and treat patients with mesothelioma prior to trimodality therapy. ANZ J Surg 2009; 79:734-8. [DOI: 10.1111/j.1445-2197.2009.05060.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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The Mesothelioma and Radical Surgery Randomized Controlled Trial: The MARS Feasibility Study. J Thorac Oncol 2009; 4:1254-8. [DOI: 10.1097/jto.0b013e3181ae26ae] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Outcome for Patients with Malignant Pleural Mesothelioma Referred for Trimodality Therapy in Western Australia. J Thorac Oncol 2009; 4:1010-6. [DOI: 10.1097/jto.0b013e3181ae25bf] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pulmonary metastasectomy: a survey of current practice amongst members of the European Society of Thoracic Surgeons. J Thorac Oncol 2009; 3:1257-66. [PMID: 18978560 DOI: 10.1097/jto.0b013e31818bd9da] [Citation(s) in RCA: 147] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Currently, no randomized trials exist to guide thoracic surgeons in the field of pulmonary metastasectomy. This study investigates the current clinical practice among European Society of Thoracic Surgeon (ESTS) members. METHODS A Web-based questionnaire was created exploring the clinical approach to lung metastasectomy. All ESTS members were surveyed. RESULTS One hundred forty-six complete responses were received from the 494 consultant ESTS members surveyed (29.6%). For most respondents (68%), lung metastasectomy represents a minor proportion (0-10%) of their clinical volume. Approximately 90% of respondents always/usually review their lung metastasectomy cases within a multidisciplinary meeting. Helical computed tomography is most commonly used (74%) for the detection of metastases, while positron emission tomography is used additionally in less than 50%. Most of respondents (92% and 74%, respectively) consider unresectable primary tumor and predicted incomplete metastasectomy as absolute contraindications to lung metastasectomy. The most frequently performed resection is wedge excision (92%). Palpation of the lung is considered necessary by 65%, while 40% use a thoracoscopic approach with therapeutic intent. Though 65% consider pathologically positive nodes a contraindication to metastasectomy, a similar number rarely/never perform mediastinoscopy before metastasectomy. At the time of metastasectomy 55% perform mediastinal lymph node sampling whereas 33% perform no nodal dissection whatsoever. CONCLUSIONS The survey provides a large, time-sensitive database summarizing the clinical practice of pulmonary metastasectomy by members of the ESTS. Responses demonstrate a remarkable consistency of practice patterns, though certain areas of potential controversy showed greater variance. Conceivably, these divergent approaches will encourage future collaborative studies aimed at identifying evidence-based practices for patients with pulmonary metastases.
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Treasure T, Fallowfield L, Farewell V, Ferry D, Lees B, Leonard P, Macbeth F, Utley M. Pulmonary metastasectomy in colorectal cancer: time for a trial. Eur J Surg Oncol 2009; 35:686-9. [PMID: 19153025 DOI: 10.1016/j.ejso.2008.12.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Revised: 12/09/2008] [Accepted: 12/12/2008] [Indexed: 01/09/2023] Open
Abstract
Pulmonary metastasectomy is undertaken for a range of cancers. The questions we raise here are specifically related to colorectal cancer, the commonest tumour for which pulmonary metastasectomy is undertaken. The primary objective of metastasectomy is to increase survival. There are no randomised trials in support of this practice nor are there any other forms of controlled studies. We present a critical look at the assumption of efficacy for this surgery and propose that a trial is needed and suggest a trial design.
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Affiliation(s)
- T Treasure
- Clinical Operational Research Unit, UCL (Department of Mathematics), 4 Taviton Street, London WC1H 0BT, UK.
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Hasegawa S, Tanaka F. Malignant mesothelioma: current status and perspective in Japan and the world. Gen Thorac Cardiovasc Surg 2008; 56:317-23. [PMID: 18607677 DOI: 10.1007/s11748-007-0243-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2007] [Indexed: 12/21/2022]
Abstract
Malignant pleural mesothelioma (MPM) is associated with a poor prognosis; and to make things worse, its incidence is increasing throughout the world. Surgical management of MPM is comprised of two aspects: diagnosis and resection. Surgical biopsy with thoracoscopy provides a higher yield but a higher rate of tumor cell seeding than blind biopsy. In some surgical cases, extended surgical staging with mediastinoscopy, laparoscopy, and contralateral thoracoscopy is required for the preoperative evaluation for resectablity. There are two types of surgical resection for MPM. Pleurectomy/decortication (P/D) involves removal of as much of the visceral, parietal, and pericardial pleura and the tumor as possible without removing the underlying lung. Because P/D is less radical but less invasive compared to extrapleural pneumonectomy (EPP), it can be tolerated by poor-risk patients. EPP comprises en bloc resection of visceral, parietal, and pericardial pleura and adjacent components such as ipsilateral lung, pericardium, and diaphragm, without opening the pleural cavity. EPP was considered a highly dangerous procedure with a surgical mortality of more than 30% decades ago, but its current operative mortality/morbidity rates are 4%-9% and 60%, respectively. As macroscopic complete resection is the primary goal of surgery for MPM because of its diffuse intrapleural growth, surgical resection alone is associated with poor survival. In this context, combination therapy with surgery plus chemotherapy and/or radiotherapy is currently considered the standard treatment for patients with respectable MPM. A national survey of EPP was conducted recently in Japan, and a few multicenter clinical trials will start soon.
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Affiliation(s)
- Seiki Hasegawa
- Department of Thoracic Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Japan.
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Abstract
Surgical metastasectomy is increasing both in the numbers of operations performed and the extensiveness of surgery that is being undertaken. Radiologists play a central role in this work. It is they who first detect metastases on cancer staging scans and it is they who detect recurrence of cancer on surveillance scans performed in the course of follow-up. Radiologists then play a key role in characterising and diagnosing any lung nodules thus discovered. For colorectal and lung cancer the clinical teams are typically quite separate, but radiologists have a role in both multidisciplinary team meetings. Thus it may well be that the radiologist is party to discussions about the same patient and the same imaging information in quite separate multidisciplinary team meetings and needs to understand the imaging needs and clinical objectives of both. As surgery is becoming more extensive, the inescapable harm done as a consequence of lung resection is increasing. Good quality evidence for benefit is lacking. The purpose of this article is to provide an update on the practice of metastasectomy, the selection of patients, the objectives of surgery, and uncertainties about its effectiveness.
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Affiliation(s)
- T Treasure
- Clinical Operational Research Unit, University College London, Gower Street, London, WC1E 6BT, UK.
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Van Meerbeeck JP, De Pauw R, Tournoy K. What is the optimal treatment of stage IIIA-N2 non-small-cell lung cancer after EORTC 08941? Expert Rev Anticancer Ther 2008; 8:199-206. [PMID: 18279061 DOI: 10.1586/14737140.8.2.199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The results of a randomized trial investigating the role of local therapies after induction chemotherapy in patients with stage IIIA-N2 non-small-cell lung cancer lend themselves to a review of the available evidence and speculation about the routine and future treatment in these patients. An algorithm for future treatment is proposed.
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Treasure T. Surgery for lung metastases from colorectal cancer: the practice examined. Expert Rev Respir Med 2007; 1:335-41. [PMID: 20477173 DOI: 10.1586/17476348.1.3.335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Operations to remove metastases in the lung have become commonplace. In this article, I give a highly critical perspective of a practice that has grown without a secure evidence base, notwithstanding more than 500 articles on the subject. The objectives are mixed and sometimes unclear. The reports are generally in the form of Kaplan-Meier survival analyses but, when challenged on the expected benefit for individuals, clinicians tend to retreat to claims for palliation rather than for 'cure'. Yet the reports include no symptom checklists, quality-of-life measures or patient-reported outcomes. I see at least four distinguishable contexts, defined by cancer types, which deserve to be considered separately: sarcoma; testicular and germ cell tumors; cancers traditionally seen as having an 'oligometastatic' pattern of behavior, such as kidney and thyroid; and the more common solid cancers, such as colorectal and breast cancer. Most surgical series group them together with a tail of one, two or three instances of the less common cancers. The inclusion in these series of all cancer types operated upon adds nothing to knowledge on cancers with low numbers and complicates the analysis for the more common ones. In this article, I will confine the discussion for the main part to colorectal cancer, which is the most common cancer in which pulmonary metastasectomy is practiced.
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Affiliation(s)
- Tom Treasure
- University College London, Clinical Operational Research Unit, Department of Mathematics, London WC1H 0BT, UK.
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