Surgery Followed by Intracavitary plus Systemic Chemotherapy in Malignant Pleural Mesothelioma

Intracavitary cisplatin-fibrin chemotherapy after surgery for malignant pleural mesothelioma: A phase I trial

OBJECTIVES

Intracavitary chemotherapy is a promising concept to improve local tumor control for malignant pleural mesothelioma with reported high morbidity rates. We have demonstrated that administration of cisplatin loaded to fibrin increased local drug concentration and reduced systemic toxicity in preclinical models. We present a phase I trial of intracavitary cisplatin-fibrin after surgical tumor resection.

METHODS

A total of 12 patients (75% International Mesothelioma Interest Group stage III-IV) were treated with 4 dose levels of intracavitary cisplatin-fibrin (11-44 mg/m² body surface area) in a dose-escalating design. Cisplatin-fibrin was sprayed on the resected surfaces after pleurectomy/decortication. Blood and tissue samples were taken to assess toxicity and pharmacokinetics. Patients were regularly followed up.

RESULTS

No dose-limiting toxicity was observed. Major morbidity occurred in 4 patients (33%). The 30-day and 90-day mortality were both 0%. Of 80 adverse events, 9 were classified serious, but none of these were related to study treatment. Local cisplatin concentration in the chest wall tissue was high at all dose levels (median, 46.3 μg/g [12-133 μg/g]). In serum, median cisplatin area under the concentration time curve values were always below renal toxicity levels. The median overall survival with 95% confidence interval was 21 months (10-31 months). In 1 patient with epithelioid malignant pleural mesothelioma (International Mesothelioma Interest Group stage I), there was no sign of relapse 48 months after treatment (44 mg/m² body surface area).

CONCLUSIONS

The administration of intracavitary cisplatin-fibrin is safe with favorable pharmacokinetics. Although most patients had advanced disease, long-term outcomes are comparable to other multimodal concepts. A confirmation phase II trial is ongoing.

Local and systemic therapies for malignant pleural mesothelioma

OPINION STATEMENT

Malignant pleural mesothelioma (MPM) is a challenging disease to treat with median overall survival times ranging between 9-17 months for all stages of disease. Recent clinical trials have improved our understanding of the biology of MPM. However, survival results are still not ideal. For early-stage MPM, patients should be evaluated for trimodality therapy in an experienced cancer center. If treating off-protocol, MPM patients should receive a surgical staging evaluation. The decision to proceed with surgical resection also should be considered after an extensive and thorough pulmonary and cardiac evaluation. If deemed a good surgical candidate, patients should receive surgical resection (pleurectomy/decortication or extrapleural pneumonectomy), adjuvant radiation therapy (hemithoracic external beam or intensity modulated radiation therapy), and either neoadjuvant or adjuvant chemotherapy (cisplatin-pemetrexed for 4 cycles). The optimal precise sequence of the trimodality is unclear and should be decided upon by a multidisciplinary consensus for each individual patient. In general, clinical trial participation should be encouraged. Several trials are currently underway to examine intraoperative therapies, vaccines, immunotherapy additions, and novel radiation therapy techniques. Advances in the field of MPM are reliant on participation in clinical trials and identifying biomarkers that are predictive for response to systemic therapies and prognostic for survival benefit.

Systematic review of pleurectomy in the treatment of malignant pleural mesothelioma

INTRODUCTION

Pleurectomy/decortication (P/D) in the treatment of malignant pleural mesothelioma includes a number of procedures with different clinical indications and therapeutic intents. To unify the nomenclature, IMIG and IASLC recently defined P/D-related procedures according to surgical technique, including 'extended P/D', 'P/D' and 'partial pleurectomy'. The present systematic review aimed to assess the safety and efficacy of these techniques.

METHODS

A systematic review of relevant studies was performed by electronic search of five online databases from 1985 to 2012 by two independent reviewers according to predefined selection criteria.

RESULTS

Thirty-four studies involving 1916 patients who underwent pleurectomy were included for quantitative analysis. These included 12 studies on 'extended P/D', 8 studies on 'P/D' and 14 studies on 'partial pleurectomy'. Perioperative mortality ranged from 0% to 11% and perioperative morbidity ranged from 13% to 43%. Median overall survival ranged from 7.1 to 31.7 months and disease-free survival ranged from 6 to 16 months. One study reported on quality-of-life outcomes using a standardized questionnaire suggesting superior outcomes for 'extended P/D' compared to extrapleural pneumonectomy.

CONCLUSIONS

Results of the present systematic review suggested similar perioperative mortality outcomes between different P/D techniques but a trend towards higher morbidity and length of hospitalization for patients who underwent 'extended P/D'. However, overall and disease-free survival appeared to favour 'extended P/D' compared to less aggressive techniques. Future studies on P/D should adhere to recent definitions to enable accurate analysis of similar procedures. Direct comparisons of pleurectomy to extrapleural pneumonectomy remain challenging, and should be restricted to 'extended P/D' procedures only.

A systematic review of lung-sparing extirpative surgery for pleural mesothelioma

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.

Optimized intrapleural cisplatin chemotherapy with a fibrin carrier after extrapleural pneumonectomy: a preclinical study

OBJECTIVE

Our objective was to evaluate whether platinum concentrations in chest wall tissue and in serum are optimized by intracavitary application of cisplatin loaded to a fibrin carrier compared with cisplatin solution in a randomized setting of a pig model.

METHODS

After left-sided pneumonectomy including parietal pleurectomy, pigs were randomly assigned to receive either 90 mg/m(2) cisplatin intracavitary solution (n = 6) or to receive 5 mg cisplatin-fibrin (n = 5) applied on a predefined area of the chest wall. Platinum concentration in serum as well as in chest wall tissue was determined at several early time points until day 5 after treatment. Platinum levels were measured by inductively coupled plasma sector field mass spectrometric detection with a matrix-matched calibration procedure.

RESULTS

The dose- and surface-corrected (geometric) mean concentration of cisplatin in chest wall tissue 2 hours but also at day 5 after the application was doubled in animals treated with cisplatin-fibrin compared with the animals treated with cisplatin-solution. In serum, the dose- and surface-corrected exposure toward cisplatin (area under the curve(0-5d)) was significantly lower with cisplatin-fibrin than with cisplatin-solution (P < .0005). This is also reflected by significantly reduced serum creatinine and urea values in the cisplatin-fibrin group (P < .0001). Animals treated with cisplatin-fibrin additionally had a significantly better postoperative course as assessed by a well-being score (P < .001).

CONCLUSIONS

After cisplatin-fibrin treatment, cisplatin tissue concentration was increased whereas systemic cisplatin concentrations were significantly reduced in comparison with cisplatin-solution treatment. This finding offers a clear advantage inasmuch as rate and severity of systemic adverse events can be reduced while local cytotoxic concentrations are at least maintained.

Surgical therapy of mesothelioma

The treatment of malignant pleural mesothelioma is controversial, particularly regarding the role of surgery. Though well accepted as a diagnostic modality, surgery is also frequently used to establish stage, provide palliation, and perhaps most controversially, to offer cytoreduction with the putative goal of delaying tumor progression and prolonging survival. Pleurectomy/decortication (PD) can achieve macroscopic complete resection; however, the ability to deliver effective postoperative radiation treatment is limited because of the risk of lung toxicity. Accordingly, it has been associated with higher rates of local recurrence compared to extrapleural pneumonectomy (EPP). Extrapleural pneumonectomy generally offers a more complete cytoreduction compared to PD but at the cost of increased morbidity and mortality. Adjuvant hemithoracic radiation is feasible following EPP and in most series local recurrence rates are lower after EPP than PD. There are no convincing data, however, to show that one procedure is superior to the other in terms of survival. Furthermore, no randomized data currently exist that demonstrate a survival benefit to any form of surgical cytoreduction over systemic treatment and supportive care. If cytoreductive surgery does have a beneficial effect on long-term survival, it will most likely be realized in patients with epithelioid tumors without nodal metastases.

Mesothelioma: path to multimodality treatment

Multimodality treatment of malignant pleural mesothelioma (MPM) with surgery, radiation therapy, and adjuvant or neoadjuvant chemotherapy is the sole path to extended survival for select patients with favorable prognostic factors. No single-modality approach has produced equivalent results. Much effort has been expended since first recognition of this insidious pleural cancer to elucidate the underlying cause and optimal treatment strategy. Despite recent breakthroughs, the principal barrier to achieving a cure rests with the propensity for disease recurrence in the ipsilateral hemithorax. Despite these limitations, however, the results hold promise for improved survival with further refinement in patient selection and targeted therapy. Other approaches to multimodality treatment have capitalized on an array of innovative technologies in search of the silver bullet strategy that will ultimately undermine the biological behavior demonstrated by MPM. These range from the use of different means of radiation delivery, biological agents, virally mediated gene therapy, photodynamic therapy, and immunotherapy. Additionally, studies using gene ratios will yield more accurate means by which to diagnose, distinguish prognosticators, and more selectively assign patients to aggressive treatments. In light of the current worldwide epidemic, the lessons learned over the past several decades serve as a humbling reminder of the treatment barriers that remain.

Neoadjuvant and intrapleural therapies for malignant pleural mesothelioma

Historically, malignant pleural mesothelioma patients with potentially resectable disease have been treated with surgery and radiation alone. With improvements in systemic and intrapleural treatment options, a movement toward multi-modality therapy has become more common. Systemic treatment options largely consist of neoadjuvant chemotherapy with platinum doublets and most recently novel targeted agents, such as dasatinib. Intrapleural strategies have included injecting chemotherapy, chemotherapy with hyper thermic per fusion, gene therapy, and immunotherapy. The following review discusses the latest results in neoadjuvant and intrapleural therapies in malignant pleural mesothelioma.

Fatal pneumonitis associated with intensity-modulated radiation therapy for mesothelioma

PURPOSE

To describe the initial experience at Dana-Farber Cancer Institute/Brigham and Women's Hospital with intensity-modulated radiation therapy (IMRT) as adjuvant therapy after extrapleural pneumonectomy (EPP) and adjuvant chemotherapy.

METHODS AND MATERIALS

The medical records of patients treated with IMRT after EPP and adjuvant chemotherapy were retrospectively reviewed. IMRT was given to a dose of 54 Gy to the clinical target volume in 1.8 Gy daily fractions. Treatment was delivered with a dynamic multileaf collimator using a sliding window technique. Eleven of 13 patients received heated intraoperative cisplatin chemotherapy (225 mg/m(2)). Two patients received neoadjuvant intravenous cisplatin/pemetrexed, and 10 patients received adjuvant cisplatin/pemetrexed chemotherapy after EPP but before radiation therapy. All patients received at least 2 cycles of intravenous chemotherapy. The contralateral lung was limited to a V20 (volume of lung receiving 20 Gy or more) of 20% and a mean lung dose (MLD) of 15 Gy. All patients underwent fluorodeoxyglucose positron emission tomography (FDG-PET) for staging, and any FDG-avid areas in the hemithorax were given a simultaneous boost of radiotherapy to 60 Gy. Statistical comparisons were done using two-sided t test.

RESULTS

Thirteen patients were treated with IMRT from December 2004 to September 2005. Six patients developed fatal pneumonitis after treatment. The median time from completion of IMRT to the onset of radiation pneumonitis was 30 days (range 5-57 days). Thirty percent of patients (4 of 13) developed acute Grade 3 nausea and vomiting. One patient developed acute Grade 3 thrombocytopenia. The median V20, MLD, and V5 (volume of lung receiving 5 Gy or more) for the patients who developed pneumonitis was 17.6% (range, 15.3-22.3%), 15.2 Gy (range, 13.3-17 Gy), and 98.6% (range, 81-100%), respectively, as compared with 10.9% (range, 5.5-24.7%) (p = 0.08), 12.9 Gy (range, 8.7-16.9 Gy) (p = 0.07), and 90% (range, 66-98.3%) (p = 0.20), respectively, for the patients who did not develop pneumonitis.

CONCLUSIONS

Intensity-modulated RT treatment for mesothelioma after EPP and adjuvant chemotherapy resulted in a high rate of fatal pneumonitis when standard dose parameters were used. We therefore recommend caution in the utilization of this technique. Our data suggest that with IMRT, metrics such as V5 and MLD should be considered in addition to V20 to determine tolerance levels in future patients.

Phase I to II study of pleurectomy/decortication and intraoperative intracavitary hyperthermic cisplatin lavage for mesothelioma

PURPOSE

To evaluate morbidity, mortality, maximum-tolerated dose (MTD), and outcome of intraoperative intracavitary hyperthermic cisplatin lavage in patients undergoing pleurectomy for malignant pleural mesothelioma (MPM).

PATIENTS AND METHODS

Sixty-one patients were prospectively registered. Forty-four resectable patients with MPM underwent pleurectomy, followed by a 1-hour lavage of the resection cavity with dose-escalated cisplatin (50, 100, 150, 175, 200, 225, and 250 mg/m2) at 42 degrees C and then intravenous sodium thiosulfate (16 g/m2 over 6 hours). Survival estimates were compared using the log-rank test and proportional hazards regression.

RESULTS

Median age was 71 years (range, 50 to 82 years). Twenty-four patients had epithelial tumors, and 20 had sarcomatous or mixed histology. Postoperative mortality was 11% (five of 44 patients). Dose-limiting renal toxicity occurred at 250 mg/m2, establishing the MTD at 225 mg/m2. Other morbidity included atrial fibrillation (14 of 44 patients, 32%) and deep venous thrombosis (four of 44 patients, 9%). Median survival time of all registered patients was 9 months, and the median survival time of resected patients was 13 months. Survival estimates differed significantly for resectable patients exposed to low doses (50 to 150 mg/m2; n = 9; median, 6 months) versus high doses (175 to 250 mg/m2; n = 35; median, 18 months) of hyperthermic cisplatin (P = .0019); recurrence-free interval also differed significantly (4 v 9 months, respectively; P < .0001). Low dose level (relative risk = 3.418) and nonepithelial histology (relative risk = 2.336) were independent risk factors for poor survival. Twenty patients with epithelial tumors who underwent high-dose cisplatin lavage had a 26-month median survival time.

CONCLUSION

Pleurectomy and high-dose intraoperative intracavitary hyperthermic cisplatin lavage is feasible in this patient population with restricted surgical options. An apparent dose-related survival benefit warrants further study.

Phase II Study of a Liposome-Entrapped Cisplatin Analog (L-NDDP) Administered Intrapleurally and Pathologic Response Rates in Patients With Malignant Pleural Mesothelioma

Purpose

To determine pathologic response rates to liposome-entrapped cis-bisneodecanoato-trans-R,R-1,2-diaminocyclohexane platinum(II) (L-NDDP) administered intrapleurally in patients with malignant pleural mesothelioma.

Patients and Methods

Thirty-three patients with malignant pleural mesothelioma and free-flowing pleural effusions received intrapleural L-NDDP once every 3 weeks at a dose of 450 mg/m2. Thoracoscopic evaluation with pleural biopsies was performed before therapy and then after every two cycles. The primary end point was pathologic response as determined by thoracoscopic biopsy.

Results

After at least two cycles, post-treatment pleural biopsy analysis was negative in 14 patients for a pathologic response rate of 42% (95% CI, 25% to 61%). Median survival was 11.2 months. There were three treatment-related deaths secondary to peritonitis, cellulitis at the thoracoscopy site, and empyema. Grade 3 nonhematologic toxicities included infection, fever, dyspnea, and anorexia, which occurred in five (15%), one (3%), one (3%), and one (3%) patients, respectively. There were no grade 4 nonhematologic toxicities. Grade 3 or 4 neutropenia, thrombocytopenia, and anemia occurred in five (15%), three (9%), and two (6%) patients, respectively. Two patients with pathologic responses subsequently underwent pleural decortication. Both surgical specimens revealed residual tumor in regions that were not in direct communication with the pleural space.

Conclusion

Intrapleural L-NDDP therapy in this patient population is feasible with significant but manageable toxicity. Although pathologic responses are highly encouraging, areas of mesothelioma that are not in direct communication with the pleural space will evade drug exposure and limit efficacy in some patients. The optimal role of intrapleural L-NDDP therapy currently remains to be determined.

Surgical management of malignant pleural mesothelioma: a systematic review and evidence summary

An evidence summary was developed for the surgical management of adult patients with diffuse or localized malignant pleural mesothelioma. This evidence summary is based on a systematic search and review of the literature published between 1985 and February 2004. Relevant studies were identified, according to pre-determined criteria by the authors and methodologists. No randomized controlled trials comparing pleurectomy (PL) with extrapleural pneumonectomy (EPP) or comparing surgery with an alternative treatment were identified. Four comparative studies, seven non-comparative prospective studies, and 16 retrospective case series were identified that looked at PL, or EPP, or PL and EPP. Trial results were not pooled due to the heterogeneity of the treatments in the trials and the fact that no trials were randomized and none were designed to directly compare different treatments. External feedback was obtained from Ontario clinicians, and the provincial Lung Cancer Disease Site Group approved the review.

CONCLUSIONS

The role of surgery in the management of malignant pleural mesothelioma cannot be precisely defined as the lack of randomized controlled clinical trials makes it impossible to determine whether the use of EPP or PL improves survival or effectively palliates the symptoms of the disease. Future studies of the role of surgery in the treatment of mesothelioma should include evaluations of quality of life.

Malignant pleural mesothelioma: surgical roles and novel therapies

Malignant pleural mesothelioma (MPM) is a uniformly fatal disease that has been recalcitrant to curative therapies. Median survivals of 8-18 months have, for the most part, led to a sense of frustration and nihilism in the medical and surgical community with regard to management of the disease, and the relatively small numbers of patients with mesothelioma have made it an orphan among other cancers with regard to research efforts and funding. This review will comment on the clinical presentation of the disease and therapeutic options that are available at this time. The role, timing, degree, and availability of cytoreductive surgery in the context of a multimodality approach for MPM will be highlighted, and various strategies that incorporate adjunctive therapies before, during, or after the operation will be discussed. Newer cytotoxic chemotherapies, either alone or in combination, are reviewed, with an emphasis on the increasing number of options with increased response rates that are becoming available for MPM patients. The results of protocols at selected centers that offer gene therapy, photodynamic therapy, hyperthermic chemotherapeutic perfusion, and intrapleural chemokines will be discussed, as well as newer preclinical approaches that base targeted therapies on novel molecular findings. In considering the newest approaches to the disease, one is encouraged to seek specialty consultation at centers that concentrate programmatic efforts on mesothelioma in order to design translational-based approaches on preclinical findings. By using such an approach, the patient and physician will find that there are considerably more options in the new century for mesothelioma.

Surgical treatment of malignant pleural mesothelioma: a review

Despite many years of clinical research, there is still no effective therapy for malignant pleural mesothelioma (MPM). Untreated, the prognosis is poor, with a median survival of < 1 year. Single-agent or combination chemotherapy as well as radiotherapy have not shown persistent improvements in response or survival. In general, MPM is a disease confined to the pleural cavity for a long time before metastasizing. Therefore, focus on local treatment seems rational. Surgical resection has been considered the mainstay of treatment by some. However, surgery alone results in high recurrence rates, and the survival benefit remains questionable. In recent years, the emphasis has been on surgery combined with adjuvant therapies. In this article, the present state of surgical management of MPM will be reviewed.

Malignant mesothelioma: options for management

In the past, there has been a tendency to think of diffuse malignant pleural mesothelioma as one disease in therapeutic terms, regardless of histological type and tumor stage. This does not happen with other tumors, yet it is equally illogical and inappropriate in mesothelioma. As with other tumors, early diagnosis-while the disease is still in stage I, or even at an in situ stage-must be the goal so that therapy can be maximized, particularly if immunotherapy or gene therapy is to be used. Patients with pure epithelial mesothelioma have a better prognosis and respond better to trimodality therapy. Stage I patients who meet fitness criteria should be offered the option of radical surgery in combination with chemotherapy and radiotherapy. Further research is required to determine the optimum neoadjuvant and adjuvant modalities, particularly the timing of individual drugs, use of hyperthermia, and route of administration. The place of immunotherapy and gene therapy as adjunctive treatments also remains to be defined. For example, it may be possible to reduce tumor bulk and perhaps downstage the disease with immunotherapy before radical surgery, if treatment is started early enough. Gene therapy may have a role either preoperatively or in destroying the microscopic disease that remains after radical surgery. These and other combinations of treatment need to be tested in well-designed clinical trials, probably on a multicenter basis (to enroll a sufficient number of patients). Finding the means to improve treatment for sarcomatous and mixed histology mesothelioma remains a challenge. At present, radical surgery does not seem worthwhile for these patients when combined with currently employed chemotherapy and radiotherapy; however, chemotherapy combinations used for treating other sarcomas need to be evaluated as adjunctive therapy before radical surgery is abandoned altogether as a mode of treatment. A collaborative approach involving thoracic surgeons, basic scientists and oncologists, and physicians with experience in treating mesothelioma is essential. Despite its increasing frequency, mesothelioma is still a relatively rare tumor, so treatment should be concentrated in relatively few supraregional centers to maximize expertise and allow innovative treatment combinations to be implemented with the greatest chance of success. Evaluation of new therapeutic approaches will be achieved more rapidly if these supraregional centers collaborate in multicenter trials. The nihilistic approach of simply waiting until the mesothelioma epidemic eventually begins to decline spontaneously in 20 or 30 years is untenable in view of the hundreds of thousands of deaths that will result if no effective treatment is found.

Cytoreductive surgery and intraoperative hyperthermic intrathoracic chemotherapy in patients with malignant pleural mesothelioma or pleural metastases of thymoma

STUDY OBJECTIVES

No established curative treatment is available for pleural thymoma metastases and malignant pleural mesothelioma (MPM). Recently, peritoneal malignancies have been treated by cytoreductive surgery and intraoperative hyperthermic intracavitary perfusion chemotherapy (HIPEC). We investigated the feasibility and safety of this multimodality treatment in the thoracic cavity.

DESIGN

Patients with pleural thymoma metastases or early-stage MPM were enrolled in a feasibility study. Morbidity, recurrence, and survival rates were recorded.

SETTING

The Netherlands Cancer Institute.

PATIENTS

Three patients with pleural thymoma metastases and 11 patients with pleural mesothelioma were treated.

INTERVENTIONS

Cytoreductive surgery and intraoperative hyperthermic intrathoracic perfusion chemotherapy (HITHOC) with cisplatin and adriamycin were performed. The mesothelioma patients received adjuvant radiotherapy on the thoracotomy wound and drainage tracts.

MEASUREMENTS AND RESULTS

Morbidity and mortality rates were 47% and 0%, respectively. Reoperation was necessary in four cases. Severe chemotherapy-related complications were not observed. A solitary mediastinal and a contralateral pleural thymoma recurrence were successfully treated by radiotherapy and a contralateral HITHOC procedure. All thymoma patients were alive and free of disease after a mean follow-up period of 18 months. After a mean follow-up period of 7.4 months, nine mesothelioma patients are alive. Two mesothelioma patients died of contralateral pleural and peritoneal recurrent disease, while one patient is alive with locoregional recurrence.

CONCLUSIONS

Cytoreductive surgery and HITHOC with cisplatin and adriamycin is feasible in patients with pleural thymoma metastases and early-stage MPM, and is associated with acceptable morbidity rates. Early data on locoregional disease control are encouraging, and a phase II study will be conducted.

A phase II trial of surgical resection and adjuvant high-dose hemithoracic radiation for malignant pleural mesothelioma

BACKGROUND

Surgical resection of malignant pleural mesothelioma is reported to have up to an 80% rate of local recurrence. We performed a phase II trial of high-dose hemithoracic radiation after complete resection to determine feasibility and to estimate rates of local recurrence and survival.

METHODS

Patients were eligible if they had a resectable tumor, as determined by computed tomographic scanning, and adequate cardiopulmonary function for extrapleural pneumonectomy or pleurectomy/decortication. After complete resection, patients received hemithoracic radiation (54 Gy) and then were followed up with serial computed tomographic scanning.

RESULTS

From 1995 to 1998, 88 patients (73 men and 15 women; median age, 62.5 years) were entered into the study. The operations performed included 62 extrapleural pneumonectomies (70%) and 5 pleurectomies/decortications; procedures for exploration only were performed in 21 patients. Seven (7.9%) patients died postoperatively. Adjuvant radiation administered to 57 patients (54 undergoing extrapleural pneumonectomy and 3 undergoing pleurectomy/decortication) at a median dose of 54 Gy was well tolerated (grade 0-2 fatigue, esophagitis), except for one late esophageal fistula. The median survival was 33.8 months for stage I and II tumors but only 10 months for stage III and IV tumors (P =.04). For the patients undergoing extrapleural pneumonectomy, the sites of recurrence were locoregional in 2, locoregional and distant in 5, and distant only in 30.

CONCLUSION

Hemithoracic radiation after complete surgical resection at a dose not previously reported is feasible. This approach dramatically reduces local recurrence and is associated with prolonged survival for early-stage tumors. Stage III disease has a high risk of early distant relapse and should be considered for trials of systemic therapy added to this regimen of resection and radiation.

Intracavitary therapies for mesothelioma

The diagnosis of mesothelioma needs to be defined histologically. The staging system has been recently redefined anatomically, but may not be applicable to extrapleural mesothelioma. Further clinicopathologic studies need to be performed to molecularly classify the disease further, according to prognosis. Intracavitary therapy has a definite role in the treatment of mesothelioma. Randomized studies of intracavitary therapies are needed to define the best treatment option. The role of complementary therapeutic modalities such as surgery and radiotherapy needs to be defined by randomized studies. There is an urgent need to better understand the biology of mesothelioma, which may lead to more focus on molecularly relevant therapies.

Advances in the treatment of malignant pleural mesothelioma

Malignant pleural mesothelioma is a neoplasm that is commonly fatal and for which there are no widely accepted curative approaches. Mesothelioma is unresponsive to most chemotherapy and radiotherapy regimens, and it typically recurs even after the most aggressive attempts at surgical resection. Multimodality approaches have been of some benefit in prolonging survival of very highly selected subgroups of patients, but they have had a relatively small impact on the majority of the patients diagnosed with this disease. As the incidence of pleural mesothelioma peaks in the United States and Europe over the next 10 to 20 years, new therapeutic measures will be necessary. This review will discuss the roles of chemotherapy, radiotherapy, surgery, and combined modality approaches in the treatment of pleural mesothelioma, as well as scientific advances made in the past decade that have led to the development of experimental techniques, such as photodynamic therapy, immunotherapy, and gene therapy, that are currently undergoing human clinical trials. These promising new avenues may modify the therapeutic nihilism that is rampant among clinicians dealing with mesothelioma.

Pleural space perfusion with cisplatin in the multimodality treatment of malignant mesothelioma: a feasibility and pharmacokinetic study

INTRODUCTION

Malignant pleural mesothelioma is an ideal model for testing new locoregional multimodality approaches because of its aggressive local behavior.

METHODS

This study was planned to investigate the feasibility, safety, and pharmacokinetics of a multimodality therapy including an operation, pleural space perfusion (60 minutes) with cisplatin (100 mg/m2), hyperthermia (41. 5 degrees C), and postoperative radiotherapy (55 Gy to chest wall incisions). The effects of the extent of resection and perfusion temperature on cisplatin pharmacokinetics were evaluated. Ten patients with epithelial or mixed, stage I or II, malignant pleural mesothelioma underwent the following procedures: group A (3 patients), pleurectomy/decortication and normothermic pleural space antineoplastic perfusion; group B (3 patients), pleurectomy/decortication and hyperthermic perfusion; and group C (4 patients), pleuropneumonectomy and hyperthermic perfusion. Operations were selectively applied depending on tumor extent. Platinum levels were serially measured by atomic absorption in systemic blood, perfusate, lung, and endothoracic fascia.

RESULTS

The overall procedure was completed in every case, without any death or toxicity. No lung damage was demonstrated after treatment. Major complications included 1 wound infection and 1 diaphragmatic prosthesis displacement. The mean peak platinum plasma levels were reached within 45 to 60 minutes after perfusion was started. Systemic drug concentrations were greater after pleurectomy/decortication than after pleuropneumonectomy (P =.006). The local tissue/perfusate ratio of platinum concentrations tended to be higher after hyperthermic perfusion rather than normothermic perfusion.

CONCLUSION

This multimodality approach is feasible, pharmacokinetically advantageous, and safe enough to undergo further clinical investigations.