Long-Term Survival Outcomes of Cancer-Directed Surgery for Malignant Pleural Mesothelioma: Propensity Score Matching Analysis

2017 ◽  
Vol 35 (29) ◽  
pp. 3354-3362 ◽  
Author(s):  
David B. Nelson ◽  
David C. Rice ◽  
Jiangong Niu ◽  
Scott Atay ◽  
Ara A. Vaporciyan ◽  
...  
Keyword(s):  
Radiation Therapy ◽  
Propensity Score ◽  
Propensity Score Matching ◽  
Median Survival ◽  
Malignant Pleural Mesothelioma ◽  
Hazard Ratio ◽  
Multimodality Therapy ◽  
Pleural Mesothelioma ◽  
National Cancer Database ◽  
Trimodality Therapy

Purpose Small observational studies have shown a survival advantage to undergoing cancer-directed surgery for malignant pleural mesothelioma (MPM); however, it is unclear if these results are generalizable. Our purpose was to evaluate survival after treatment of MPM with cancer-directed surgery and to explore the effect surgery interaction with chemotherapy or radiation therapy on survival by using the National Cancer Database. Patients and Methods Patients with microscopically proven MPM were identified within the National Cancer Database (2004 to 2014). Propensity score matching was performed 1:2 and among this cohort, a Cox proportional hazards regression model was used to identify predictors of survival. Median survival was calculated by using the Kaplan-Meier method. Results Of 20,561 patients with MPM, 6,645 were identified in the matched cohort, among whom 2,166 underwent no therapy, 2,015 underwent chemotherapy alone, 850 underwent cancer-directed surgery alone, 988 underwent surgery with chemotherapy, and 274 underwent trimodality therapy. The remaining 352 patients underwent another combination of surgery, radiation, or chemotherapy. Thirty-day and 90-day mortality rates were 6.3% and 15.5%. Cancer-directed surgery, chemotherapy, and radiation therapy were independently associated with improved survival (hazard ratio, 0.77, 0.74, and 0.88, respectively). Stratified analysis revealed that surgery-based multimodality therapy demonstrated an improved survival compared with surgery alone, with no significant difference between surgery-based multimodality therapies; however, the largest estimated effect was when cancer-directed surgery, chemotherapy, and radiation therapy were combined (hazard ratio, 0.52). For patients with the epithelial subtype who underwent trimodality therapy, median survival was extended from 14.5 months to 23.4 months. Conclusion MPM is an aggressive and rapidly fatal disease. Surgery-based multimodality therapy was associated with improved survival and may offer therapeutic benefit among carefully selected patients.

Trimodality Therapy With Induction Chemotherapy Followed by Extrapleural Pneumonectomy and Adjuvant High-Dose Hemithoracic Radiation for Malignant Pleural Mesothelioma

2009 ◽  
Vol 27 (9) ◽  
pp. 1413-1418 ◽  
Author(s):  
Marc de Perrot ◽  
Ronald Feld ◽  
B.C. John Cho ◽  
Andrea Bezjak ◽  
Masaki Anraku ◽  
...  
Keyword(s):  
Radiation Therapy ◽  
Induction Chemotherapy ◽  
Malignant Pleural Mesothelioma ◽  
Disease Free Survival ◽  
Extrapleural Pneumonectomy ◽  
High Dose ◽  
Pleural Mesothelioma ◽  
Trimodality Therapy ◽  
Single Center Experience ◽  
N2 Disease

Purpose Malignant pleural mesothelioma (MPM) remains associated with poor outcome. We examined the results of trimodality therapy with cisplatin-based chemotherapy followed by extrapleural pneumonectomy (EPP) and adjuvant high-dose (50 to 60 Gy) hemithoracic radiation therapy for MPM. Patients and Methods We conducted a retrospective review of all patients prospectively evaluated for trimodality therapy protocol between January 2001 and December 2007 in our institution. Results A total of 60 patients were suitable candidates. Histology was epithelioid (n = 44) or biphasic (n = 16). Chemotherapy regimens included cisplatin/vinorelbine (n = 26), cisplatin/pemetrexed (n = 24), cisplatin/raltitrexed (n = 6), or cisplatin/gemcitabine (n = 4). EPP was performed in 45 patients, and hemithoracic radiation therapy to at least 50 Gy was administered postoperatively to 30 patients. Completion of the trimodality therapy in the absence of mediastinal node involvement was associated with the best survival (median survival of 59 months v ≤ 14 months in the remaining patients, P = .0003). The type of induction chemotherapy had no significant impact on survival. Pathologic nodal status remained a significant predictor of poor survival despite completion of the trimodality therapy. After completion of the protocol, the 5-year disease-free survival was 53% for patients with N0 disease, reaching 75% in patients with ypT1-2N0 and 45% in patients with ypT3-4N0. Conclusion This large, single-center experience with induction chemotherapy followed by EPP and adjuvant high-dose hemithoracic radiation for MPM shows that half of the patients are able to complete this protocol. The results are encouraging for patients with N0 disease. However, N2 disease remains a major factor impacting on survival, despite completion of the entire trimodality regimen.

Comparison of outcomes in patients with locally advanced pancreatic adenocarcinoma treated with stereotactic body radiation therapy (SBRT) versus conventionally fractionated radiation: An analysis of the National Cancer Database.

2017 ◽  
Vol 35 (4_suppl) ◽  
pp. 366-366
Author(s):  
Jim Zhong ◽  
Kirtesh R. Patel ◽  
Jeffrey M. Switchenko ◽  
Theresa Wicklin Gillespie ◽  
Richard John Cassidy ◽  
...  
Keyword(s):  
Radiation Therapy ◽  
Propensity Score ◽  
Propensity Score Matching ◽  
Locally Advanced ◽  
Multivariable Analysis ◽  
Advanced Pancreatic Cancer ◽  
Rank Test ◽  
National Cancer Database ◽  
Fractionated Radiation ◽  
Conventionally Fractionated

366 Background: As systemic therapy has improved for locally advanced pancreatic cancer (LAPC), efforts to improve local control have become critical. While conventionally fractionated radiation therapy (CFRT) has more recently shown a limited role in LAPC, stereotactic body irradiation (SBRT) is an emerging approach that delivers higher doses of radiation therapy, to small volumes, over a much shorter period of time. With no studies to date comparing SBRT to CFRT for LAPC, we utilized the National Cancer Database (NCDB) to evaluate these two modalities. Methods: Using the NCDB, patients with AJCC clinic cT2-4, N0-1, M0 adenocarcinoma of the pancreas diagnosed from 2004-2013 were analyzed. Radiation therapy delivered at 2 Gy per fraction or less was deemed CFRT, and 4 Gy or more per fraction was considered SBRT to allow inclusion of practice variations. Kaplan-Meier, log-rank test, and multivariable Cox proportional hazards regression were performed with overall survival (OS) as the primary outcome. Propensity score matching was employed to reduce treatment selection bias. Results: Among 8,450 patients, 7,819 (92.5%) were treated with CFRT, and 631 (7.5%) underwent SBRT. The median dose per fraction and number of fractions for CFRT and SBRT cohorts were 1.8 Gy per fraction in 28 fractions and 8 Gy per fraction in 5 fractions, respectively. Using propensity score matching, 988 patients were matched, with 494 patients in each cohort. Within the propensity-matched cohorts, the median OS was higher with SBRT (13.9 vs. 10.7 months), and 2-year OS of 21.5% and 15.9% for the SBRT and CFRT groups, respectively ( p = 0.0014). Multivariable analysis confirmed SBRT was a significant predictor for OS (Hazard ratio:0.84; 95% confidence interval: 0.75-0.93, p = 0.001). Additionally, pancreatoduodenectomy, low comorbidity index, chemotherapy use, and node negative disease also positively impacted survival. Conclusions: SBRT appears to be associated with an improved OS compared to CFRT for LAPC. Further prospective studies investigating these hypothesis-generating results are warranted.

scholarly journals Multicenter Phase II Trial of Neoadjuvant Pemetrexed Plus Cisplatin Followed by Extrapleural Pneumonectomy and Radiation for Malignant Pleural Mesothelioma

2009 ◽  
Vol 27 (18) ◽  
pp. 3007-3013 ◽  
Author(s):  
Lee M. Krug ◽  
Harvey I. Pass ◽  
Valerie W. Rusch ◽  
Hedy L. Kindler ◽  
David J. Sugarbaker ◽  
...  
Keyword(s):  
Survival Rate ◽  
Median Survival ◽  
Malignant Pleural Mesothelioma ◽  
Pathologic Complete Response ◽  
Disease Stage ◽  
Extrapleural Pneumonectomy ◽  
Pleural Mesothelioma ◽  
Term Survival ◽  
Trimodality Therapy ◽  
Response To Chemotherapy

Purpose Neoadjuvant pemetrexed plus cisplatin was administered, followed by extrapleural pneumonectomy (EPP) and hemithoracic radiation (RT), to assess the feasibility and efficacy of trimodality therapy in stage I to III malignant pleural mesothelioma. Patients and Methods Requirements included stage T1-3 N0-2 disease, no prior surgical resection, adequate organ function (including predicted postoperative forced expiratory volume in 1 second ≥ 35%), and performance status 0 to 1. Patients received pemetrexed 500 mg/m2 plus cisplatin 75 mg/m2 for four cycles. Patients without disease progression underwent EPP followed by RT (54 Gy). The primary end point was pathologic complete response (pCR) rate. Results Seventy-seven patients received chemotherapy. All four cycles were administered to 83% of patients. The radiologic response rate was 32.5% (95% CI, 22.2 to 44.1). Fifty-seven patients proceeded to EPP, which was completed in 54 patients. Three pCRs were observed (5% of EPP). Forty of 44 patients completed irradiation. Median survival in the overall population was 16.8 months (95% CI, 13.6 to 23.2 months; censorship, 33.8%). Patients completing all therapy had a median survival of 29.1 months and a 2-year survival rate of 61.2%. Radiologic response of complete or partial response was associated with a median survival of 26.0 months compared with 13.9 months for patients with stable disease or progressive disease (P = .05). Conclusion This multicenter trial showed that trimodality therapy with neoadjuvant pemetrexed plus cisplatin is feasible with a reasonable long-term survival rate, particularly for patients who completed all therapy. Radiologic response to chemotherapy, but not sex, histology, disease stage, or nodal status, was associated with improved survival.

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