The MARS feasibility trial: conclusions not supported by data – Authors' reply

Surgical Options for Malignant Mesothelioma: A Single-Center Experience

Background

We investigated the surgical outcomes of patients who underwent therapeutic surgery for malignant pleural mesothelioma (MPM) at a single center.

Methods

A retrospective review of 21 patients who underwent therapeutic surgery for MPM from January 2001 to June 2015 was conducted to assess their outcomes. The patients’ characteristics and postoperative course, including complications, mortality, overall survival, and recurrence-free survival, were analyzed.

Results

Of the 21 patients who underwent therapeutic surgery, 15 (71.4%) underwent extrapleural pneumonectomy, 2 pleurectomy (9.5%), and 4 excision (19.1 %). The median age was 57 years (range, 32–79 years) and 15 were men (71.4%). The mean hospital stay was 16 days (range, 1–63 days). Median survival was 14.3 months. The survival rate was 54.2%, 35.6%, and 21.3% at 1, 3, and 5 years, respectively. In patients’ postoperative course, heart failure was a major complication, occurring in 3 patients (14.3%). The in-hospital mortality rate was 2 of 21 (9.5%) due to a case of severe pneumonia and a case of acute heart failure.

Conclusion

A fair 5-year survival rate of 21.3% was observed after surgical treatment. Heart failure was a major complication in our cohort. Various surgical methods can be utilized with MPM, each with its own benefits, taking into consideration the severity of the disease and the comorbidities of the patient. Patients with local recurrence may be candidates for surgical intervention, with possible satisfying results.

Surgical Management of Malignant Pleural Mesothelioma: An Update of Clinical Evidence

To investigate the surgical management of malignant pleural mesothelioma, 2 randomized controlled trials have been completed. We discuss the findings from these trials and the current evidence of various surgical techniques to treat this challenging disease.

Malignant pleural mesothelioma and the Society of Thoracic Surgeons Database: an analysis of surgical morbidity and mortality

BACKGROUND

To date, reported surgical morbidity and mortality for pleurectomy/decortication and extrapleural pneumonectomy performed for malignant pleural mesothelioma primarily represent the experience of a few specialized centers. For comparison, we examined early outcomes of pleurectomy/decortication and extrapleural pneumonectomy from a broader group of centers/surgeons participating in the Society of Thoracic Surgeons-General Thoracic Database.

METHODS

All patients in the Society of Thoracic Surgeons-General Thoracic Database (version 2.081, representing 2009-2011) who underwent pleurectomy/decortication or extrapleural pneumonectomy for malignant pleural mesothelioma were identified. Patient characteristics, morbidity, mortality, center volume, and procedure were examined using univariable and multivariable analyses.

RESULTS

A total of 225 patients underwent pleurectomy/decortication (n = 130) or extrapleural pneumonectomy (n = 95) for malignant pleural mesothelioma at 48 centers. Higher volumes of procedures (≥5/y) were performed at 3 pleurectomy/decortication and 2 extrapleural pneumonectomy centers. Patient characteristics were statistically equivalent between pleurectomy/decortication and extrapleural pneumonectomy groups, except those undergoing extrapleural pneumonectomy were younger (63.2 ± 7.8 years vs 68.3 ± 9.5 years; P < .001) and more likely to have received preoperative chemotherapy (30.1% vs 17.8%; P = .036). Major morbidity was greater after extrapleural pneumonectomy, including acute respiratory distress syndrome (8.4% vs 0.8%; P = .005), reintubation (14.7% vs 2.3%; P = .001), unexpected reoperation (9.5% vs 1.5%; P = .01), and sepsis (4.2% vs 0%; P = .03), as was mortality (10.5% vs 3.1%; P = .03). Multivariate analyses revealed that extrapleural pneumonectomy was an independent predictor of major morbidity or mortality (odds ratio, 6.51; P = .001). Compared with high-volume centers, increased acute respiratory distress syndrome was seen in low-volume centers performing extrapleural pneumonectomy (0% vs 12.5%; P = .05).

CONCLUSIONS

Extrapleural pneumonectomy is associated with greater morbidity and mortality compared with pleurectomy/decortication when performed by participating surgeons of the Society of Thoracic Surgeons-General Thoracic Database. Effects of center volume require further study.

Surgery in the treatment of malignant pleural mesothelioma: recruitment into trials should be the default position

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.