scholarly journals Multimodality treatment of malignant pleural mesothelioma

F1000Research ◽  
2018 ◽  
Vol 7 ◽  
pp. 1681 ◽  
Author(s):  
Lawek Berzenji ◽  
Paul Van Schil
Keyword(s):  
Malignant Pleural Mesothelioma ◽  
Asbestos Exposure ◽  
Multimodality Treatment ◽  
Treatment Modalities ◽  
Surgical Approaches ◽  
Extrapleural Pneumonectomy ◽  
Pleural Mesothelioma ◽  
Treatment Approaches ◽  
Definitive Answer ◽  
Platinum Based Chemotherapy

Malignant pleural mesothelioma (MPM) is a rare disease of the pleura and is largely related to asbestos exposure. Despite recent advancements in technologies and a greater understanding of the disease, the prognosis of MPM remains poor; the median overall survival rate is about 6 to 9 months in untreated patients. The main therapeutic strategies for MPM are surgery, chemotherapy, and radiation therapy (RT). The two main surgical approaches for MPM are extrapleural pneumonectomy (EPP), in which the lung is removed en bloc, and pleurectomy/decortication, in which the lung stays in situ. Chemotherapy usually consists of a platinum-based chemotherapy, such as cisplatin, often combined with a folate antimetabolite, such as pemetrexed. More recently, immunotherapy has emerged as a possible therapeutic strategy for MPM. Evidence suggests that single-modality treatments are not an effective therapeutic approach for MPM. Therefore, researchers have started to explore different multimodality treatment approaches, in which often combinations of surgery, chemotherapy, immunotherapy, and RT are investigated. There is still no definitive answer to the question of which multimodality treatment combinations are most effective in improving the poor prognosis of MPM. Research into the effects of trimodality treatment approaches have found that radical approaches such as EPP and hemithoracic RT post-EPP are less effective than was previously assumed. In general, there are still a great number of unanswered questions and unknown factors regarding the ideal treatment approach for MPM. Hopefully, more research into multimodality therapy will provide insight into which combination of treatment modalities is most effective.

scholarly journals Malignant Pleural Mesothelioma Outcomes in the Era of Combined Platinum and Folate Antimetabolite Chemotherapy

2015 ◽  
Vol 2015 ◽  
pp. 1-7 ◽  
Author(s):  
Mathieu D. Saint-Pierre ◽  
Christopher Pease ◽  
Hamid Mithoowani ◽  
Tinghua Zhang ◽  
Garth A. Nicholas ◽  
...  
Keyword(s):  
Overall Survival ◽  
Malignant Pleural Mesothelioma ◽  
Asbestos Exposure ◽  
Performance Status ◽  
Treatment Modalities ◽  
Pleural Mesothelioma ◽  
Cox Models ◽  
Platinum Based Chemotherapy ◽  
Before And After ◽  
Incremental Improvement

Introduction. Malignant pleural mesothelioma (MPM) is associated with a poor prognosis. Palliative platinum-based chemotherapy may help to improve symptoms and prolong life. Since 2004, the platinum is commonly partnered with a folate antimetabolite. We performed a review investigating if survival had significantly changed before and after the arrival of folate antimetabolites in clinical practice. Methods. All MPM patients from January 1991 to June 2012 were identified. Data collected included age, gender, asbestos exposure, presenting signs/symptoms, performance status, histology, stage, bloodwork, treatment modalities including chemotherapy, and date of death or last follow-up. The primary endpoint was overall survival. Cox models were applied to determine variables associated with survival. Results. There were 245 patients identified. Median overall survival for all patients was 9.4 months. After multivariate analysis, performance status, stage, histology, leucocytosis, and thrombophilia remained independently associated with survival. Among all patients who received chemotherapy, there was no difference in overall survival between the periods before and after folate antimetabolite approval: 14.2 versus 13.2 months (P=0.35). Specifically receiving combined platinum-based/folate antimetabolite chemotherapy did not improve overall survival compared to all other chemotherapy regimens: 14.1 versus 13.6 months (P=0.97). Conclusions. In this review, we did not observe an incremental improvement in overall survival after folate antimetabolites became available.

Case 13.8

2014 ◽  
pp. 628-629
Author(s):  
Christine U. Lee ◽  
James F. Glockner
Keyword(s):  
Malignant Pleural Mesothelioma ◽  
Asbestos Exposure ◽  
The United States ◽  
Extrapleural Pneumonectomy ◽  
Parietal Pleura ◽  
Pleural Mesothelioma ◽  
Pleural Plaques ◽  
Abnormal Chest ◽  
Left Pleura ◽  
Histologic Subtypes

62-year-old man with shortness of breath and an abnormal chest CT Axial 3D SPGR postgadolinium images (Figure 13.8.1) demonstrate diffuse thickening and enhancement of the left pleura, with a few minimally enhancing, focal right-sided pleural plaques. Malignant pleural mesothelioma Malignant pleural mesothelioma is a rare neoplasm that originates from the mesothelial cells lining the visceral and parietal pleura. The incidence of malignant pleural mesothelioma in the United States is 15 cases per million; there is a strong correlation with asbestos exposure. Malignant pleural mesothelioma is divided into 3 histologic subtypes: epithelial (55%-65%), sarcomatoid (10%-15%), and mixed (20%-35%). Patients with epithelial malignant pleural mesothelioma have the best prognosis, and among those with limited disease who undergo extrapleural pneumonectomy (removal of the pleura, lung, hemidiaphragm, and part of the pericardium), survival is longer (5-year survival, 39%) than among all patients (median survival, 8-18 months after diagnosis)....

Prognostic factors in malignant pleural mesothelioma (MPM): A mono-institutional evaluation of Bologna Malignant Pleural Mesothelioma Group.

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. e18509-e18509
Author(s):  
Daniela Adua ◽  
Francesca Sperandi ◽  
Paolo Castellucci ◽  
Barbara Melotti ◽  
Stefania Giaquinta ◽  
...  
Keyword(s):  
Prognostic Factors ◽  
Prognostic Factor ◽  
Malignant Pleural Mesothelioma ◽  
Cox Regression ◽  
Statistical Significance ◽  
Multimodality Treatment ◽  
Extrapleural Pneumonectomy ◽  
Pleural Mesothelioma ◽  
Histological Subtype ◽  
The Impact

e18509 Background: The prognostic systems currently in use in MPM, such as the EORTC and CALGB score, include the clinical and histological parameters, excluding the FDG-PET (PET) evaluation and the possibility of surgery. The aim of our study was to investigate the role of PET baseline SUV-max and surgery as prognostic factors in MPM. Methods: From April 2002to December 2012, 48 pts with a certain histological diagnosis of MPM underwent staging by PET scan before peri-operative (multimodality treatment) or palliative first-line chemotherapy (CT). Surgery was performed in 22(45.8%) pts. Pt characteristics: males 44(91.7%), females 4(8.3%); median age 65 (51-77) years; ECOG PS 0-1 45(93.7 %), PS 2 3(6.3 %); IMIG stage I-II 18(37.5%), III-IV 30(62.5%); histological subtype epithelial 40(83.3%), mixed 5(10.4%), sarcomatoid 3(6.3%); extrapleural pneumonectomy 8(16.8%), pleurectomy/decortication 14(29.2%), 17 (35.4%) VATS plus pleurodesis, 19(39.6%) no surgical procedures. Platinum based CT was performed in combination with pemetrexed in 39(81.3%) pts and with gemcitabine in 9(18.7%). According to the EORTC score 30(62.5%) pts were classified in the good prognosis group and 18(37.5%) as poor prognosis. The cut-off value of PET baseline SUV-max calculated by ROC analysis was 9; SUV-max at baseline PET was ≤ 9 in 32(66.7%) pts and >9 in 16(33.3%). Median overall survival (OS) was 12 (3-60) months. Results: Upon validating the impact of individual factors on OS using the Kaplan-Meier analysis, we found statistical significance was reached by histology (p=0.0038) and surgery (p=0.0027). In a multivariate analysis using the Cox regression system, considering OS as a dependent variable, according to age, histology, stage, PET baseline SUV-max and surgery, epithelial histology (p =0.002) and surgery (p=0.012) achieved a statistical significance. SUV-max at baseline PET was not statistically significant (p = 0.290), excluding it as a possible independent prognostic factor in MPM. Conclusions: This analysis does not indicate any prognostic value for baseline PET in MPM, confirming the importance of histological subtype and introducing surgery as a possible prognostic factor.

scholarly journals Relapse Patterns and Tailored Treatment Strategies for Malignant Pleural Mesothelioma Recurrence after Multimodality Therapy

2021 ◽  
Vol 10 (5) ◽  
pp. 1134
Author(s):  
Alice Bellini ◽  
Andrea Dell’Amore ◽  
Stefano Terzi ◽  
Giovanni Zambello ◽  
Andrea Zuin ◽  
...  
Keyword(s):  
Malignant Pleural Mesothelioma ◽  
Treatment Strategies ◽  
Multimodality Treatment ◽  
Best Supportive Care ◽  
Frequent Pattern ◽  
Extrapleural Pneumonectomy ◽  
Pleural Mesothelioma ◽  
Appropriate Treatment ◽  
Study Population ◽  
Distant Spread

To date, there have been no established therapies for recurrent malignant pleural mesothelioma (MPM) after multimodality treatment. Aims of this retrospective study are to analyze the recurrence pattern, its treatment and to identify the predictors of best oncological outcomes for relapsed MPM, comparing extrapleural pneumonectomy (EPP) vs. pleurectomy/decortication (PD). Study population: 94 patients with recurrence of MPM after multimodality treatment underwent macroscopic complete resection (52.1% with EPP and 47.9% with PD) between July 1994 and February 2020. Distant spread was the most frequent pattern of recurrence (71.3%), mostly in the EPP group, while the PD group showed a higher local-only failure rate. Post-recurrence treatment was administered in 86.2%, whereas best supportive care was administered in 13.8%. Median post-recurrence survival (PRS) was 12 months (EPP 14 vs. PD 8 months, p = 0.4338). At multivariate analysis, predictors of best PRS were epithelial histology (p = 0.026, HR 0.491, IC95% 0.263–0.916), local failure (p = 0.027, HR 0.707, IC95% 0.521–0.961), DFS ≥ 12 months (p = 0.006, HR 0.298, IC95% 0.137–0.812) and post-recurrence medical treatment (p = 0.046, HR 0.101, IC95% 0.897–0.936). The type of surgical intervention seems not to influence the PRS if patients are fit enough to face post-recurrence treatments. In patients with a prolonged disease-free interval, in the case of recurrence the most appropriate treatment seems to be the systemic medical therapy, even in the case of local-only relapse.

scholarly journals Cancer-directed surgery in malignant pleural mesothelioma: extrapleural pneumonectomy and pleurectomy/decortication

2021 ◽  
Author(s):  
Brian Housman ◽  
Andrea S. Wolf
Keyword(s):  
Malignant Pleural Mesothelioma ◽  
Asbestos Exposure ◽  
Morbidity Rate ◽  
Extrapleural Pneumonectomy ◽  
High Morbidity ◽  
Pleural Mesothelioma ◽  
Solid Malignancy ◽  
Future Treatment ◽  
High Morbidity Rate ◽  
Therapeutic Alternatives

Malignant pleural mesothelioma (MPM) is a primary solid malignancy related to inhalational asbestos exposure. Despite advances in therapy, MPM remains challenging to treat with a post-treatment survival of only 15% at 5-year. In recent years, extra-pleural pneumonectomy has decreased in popularity due to a high morbidity rate and mortality compared to pleurectomy/decortication and other therapeutic alternatives. In this review, we will discuss both procedures, outcomes, ongoing studies, and the roles of surgery in the future treatment of this disease.

Progress in the Understanding of the Immune Microenvironment and Immunotherapy in Malignant Pleural Mesothelioma

2020 ◽  
Vol 21 (15) ◽  
pp. 1606-1612 ◽  
Author(s):  
Lei Cheng ◽  
Na Li ◽  
Xiao-ling Xu ◽  
Wei-Min Mao
Keyword(s):  
Tumor Microenvironment ◽  
Malignant Pleural Mesothelioma ◽  
Asbestos Exposure ◽  
Extrapleural Pneumonectomy ◽  
Pleural Mesothelioma ◽  
Immune Microenvironment ◽  
Tumor Immune Microenvironment ◽  
Mechanism Of Carcinogenesis ◽  
Cycle Regulation ◽  
The Relationship

Malignant pleural mesothelioma (MPM) is a remarkably aggressive thoracic malignancy with a limited survival of only 5-12 months. However, MPM still remains unresponsive to conventional standards of treatment, including pleurectomy and decortication, extrapleural pneumonectomy for resectable disease with or without chemotherapy, and/or radiation therapy. The mechanism of carcinogenesis has not been fully elucidated, although approximately 80% of cases can still be linked to asbestos exposure. The tumor immune microenvironment (TME) has been proven to play an important role in MPM pathogenesis and treatment outcomes. Several molecular pathways have been implicated in the MPM tumor microenvironment, such as angiogenesis, apoptosis, cell cycle regulation, and stromal processes. Immunotherapy has already shown promising results in other thoracic solid tumors, such as non-small-cell lung cancer (NSCLC). However, immunotherapy has shown less convincing results in MPM than in melanoma and NSCLC. A multicenter, randomized trial (DETERMINE) proved that immune checkpoint inhibition using tremelimumab, an anti-cytotoxic T lymphocyteassociated protein 4 (CTLA-4) antibody, failed to improve median overall survival. Therefore, it is important to explore the relationship between the characteristics of the tumor microenvironment and immunotherapy. Here, we review the heterogeneity of the TME and the progress in the understanding of the immune microenvironment and immunotherapy in MPM to explore the mechanisms of resistance to immunotherapy.

Comparison of prognostic impact between metabolic and radiologic response after induction chemotherapy for resectable malignant pleural mesothelioma: A multicenter study.

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. 7031-7031
Author(s):  
Yasuhiro Tsutani ◽  
Teruhisa Takuwa ◽  
Yoshihiro Miyata ◽  
Kazuya Fukuoka ◽  
Seiki Hasegawa ◽  
...  
Keyword(s):  
Induction Chemotherapy ◽  
Malignant Pleural Mesothelioma ◽  
Multicenter Study ◽  
Fdg Pet ◽  
Metabolic Response ◽  
Standardized Uptake Value ◽  
Extrapleural Pneumonectomy ◽  
Pleural Mesothelioma ◽  
Prognostic Impact ◽  
Platinum Based Chemotherapy

7031 Background: Induction chemotherapy followed by extrapleural pneumonectomy (EPP) for resectable malignant pleural mesothelioma (MPM) is controversial. To select optimal candidates for EPP, we evaluates the usefulness of metabolic response on fluorodeoxyglucose-positron emission tomography (FDG-PET) compared with radiologic response on high-resolution computed tomography (HRCT) after induction chemotherapy to predict prognosis for patients with resectable MPM who underwent EPP in the setting of multicenter study. Methods: We performed HRCT and FDG-PET before and after induction platinum-based chemotherapy on 50 patients with clinical T1-3 N0-2 M0 MPM who underwent EPP ± postoperative hemithoracic radiation. A decrease of more than 30% in tumor maximum standardized uptake value (SUVmax) was defined as a metabolic responder. Radiologic response using modified RECIST or metabolic response and surgical results were analyzed. Results: In all cohort patients, median overall survival (OS) from diagnosis was 20.5 month (95% confidence interval [CI], 15.0-26.0 month). Fourteen patients were classified as metabolic responders (28%) and 36 as non-responders (72%). Metabolic responders significantly correlated to OS with median OS for metabolic responders of not reached (3-year OS of 60.0%) versus 18.7 month (95% CI, 13.3-24.2 month, 3-year OS of 26.5%) for non-responders (P = .025). No correlation was observed between OS and radiologic response with median OS for radiologic responders of 25.7 month (n = 20, 95% CI, 14.5-37.0 month, 3-year OS of 35.8%) versus 17.7 month (n = 30, 95% CI, 12.8-22.6 month, 3-year OS of 35.1%) for non-responder (p = .216). Based on the multivariate Cox analyses, decreased SUVmax (%) (p = .010) was a significantly independent factor for OS as well as epithelioid subtype (p = .044). Conclusions: Metabolic response on FDG-PET has higher predictive value of prognosis than radiologic response on HRCT after induction chemotherapy for patients with resectable MPM. Patients with metabolic responder and/or epithelioid subtype can be good candidates for EPP after induction chemotherapy.

scholarly journals Trimodality Treatment in Malignant Pleural Mesothelioma: An Ordeal or The Real Deal?

2020 ◽  
Author(s):  
Naveen Mummudi ◽  
Asfiya Khan ◽  
Anil Tibdewal ◽  
Rajiv Kumar ◽  
Sabita Jiwnani ◽  
...  
Keyword(s):  
Malignant Pleural Mesothelioma ◽  
Organs At Risk ◽  
Asbestos Exposure ◽  
Multimodality Treatment ◽  
Target Volume ◽  
Conventional Technique ◽  
Pleural Mesothelioma ◽  
Medical Systems ◽  
Dosimetric Data ◽  
Trimodality Treatment

BACKGROUND: Malignant Pleural Mesothelioma is an uncommon and aggressive disease associated with asbestos exposure. Management of MPM is complex and controversial as there is paucity of good quality evidence. Multimodality treatment with surgery, systemic therapy and radiation therapy is an option in non-metastatic MPM. We intend to analyze toxicity and outcomes in patients who received trimodality treatment for non-metastatic MPM at our institution. METHODS and MATERIALS: We reviewed the electronic medical records of surgically managed MPM patients at our institution in the last decade. Patient details, disease characteristics and treatment information were retrieved from the institutional electronic medical record and radiation oncology information system. Dosimetric parameters of target volume and organs at risk were documented from Eclipse workstation (v13.6, Varian medical systems). SPSS was used for statistical analysis. RESULTS: Between January 2008 and October 2018, 21 patients (17 male and 4 female) underwent surgery for MPM, all but 2 patients underwent extra-pleural pneumonectomy (EPP). Primary was located in the right and left in 11 and 10 patients respectively. Epithelioid MPM was the commonest histology (17 patients: 81%). Resection was R0 in 18 patients and R2 in 2 patients. Four patients had minor complications like wound erythema, wound seroma with cellulitis and hypotension and 8 Patients had major complications like pneumonia, rib fracture, pulmonary hypertension and pulmonary stump thrombus. All patients received neoadjuvant Pemetrexed/platinum doublet chemotherapy, except for 2. Fourteen patients received adjuvant hemithoracic RT; of these, 2 underwent treatment elsewhere and 2 were treated with conventional technique. Ten patients treated with conformal technique at our institute and dosimetric data was available for analysis. Average time to start RT after surgery was 51 days (range 32 to 82 days). All patients were treated with conformal technique using IMRT/VMAT to a dose of 45Gy in 25 fractions; one patient received a further boost of 5.4Gy. Mean overall RT duration was 35 days (range 30 to 42 days). Acute toxicity was uncommon; Grade I/II Pneumonitis was seen in 4 patients. One patient developed grade III acute lung toxicity unrelated to RT. At a median follow up of 25 months, 8 patients developed progressive disease. Eight patients had died, of whom six died due to disease and two died in immediate post op period. Two-year DFS and OS were 58% and 73% respectively. CONCLUSION: In spite of the extensive surgery and complex hemithoracic RT, we demonstrated excellent dosimetric, toxicity profile and favorable outcomes in non-metastatic MPM.

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