Surgical management of malignant pleural mesothelioma: a systematic review and evidence summary
Introduction
Mesotheliomas are neoplasms of the serosal membranes, with 80% originating in the pleural space. In fact, pleural mesothelioma is the most common primary tumour of the pleural cavity [1]. The Surveillance, Epidemiology, and End Results Registry of the National Cancer Institute of the United States reported an age-adjusted incidence rate of 1.1078 (95% confidence interval [CI]: 1.0634–1.1535) cases per 100,000 people [2]. Each year, approximately 100 Canadians will be diagnosed with malignant mesothelioma [3], with an estimated median survival of 4–12 months for untreated disease [4]. Mesotheliomas were, in the past, classified into three general categories (diffuse malignant, localized benign, and localized malignant), although most clinical studies do not specifically report these disease categories. Since diffuse malignant pleural mesothelioma was first described as a distinct disease, its treatment has been associated with controversy. Treatment of this disease has included various combinations of surgery, radiation, and chemotherapy. The two main surgical treatment approaches are pleurectomy (PL) and extrapleural pneumonectomy (EPP). The former procedure generally involves excision of sections of the pleura. The latter procedure is a more aggressive approach, which involves the removal of all or part of a lung, as well as the parietal pleura, ipsilateral pericardium, and diaphragm. This evidence summary focuses on the role of surgery, specifically PL and EPP, in the treatment of diffuse and localized malignant mesothelioma, for which, no widely accepted standard of care currently exists. Outcomes of interest include clinical or sub-clinical adverse effects, survival, recurrence rates, prognostic factors, and quality of life.
Section snippets
Evidence summary development
This evidence summary report was developed by the Practice Guidelines Initiative (PGI) of Cancer Care Ontario's Program in Evidence-based Care, using the methods of the Practice Guidelines Development Cycle [5]. The PGI is sponsored by, but is editorially independent of, Cancer Care Ontario and the Ontario Ministry of Health and Long-term Care. An evidence summary report contains the best evidence available on a specific clinical question when there is insufficient high-quality evidence on
Literature search results
No randomized controlled trials comparing PL with EPP or comparing surgery with an alternative treatment in patients with malignant pleural mesothelioma were identified. A total of 32 studies met the inclusion criteria (Table 1, Table 2, Table 3) and included the following: non-controlled prospective studies with case-series designs or comparative designs not containing similar, concurrent comparison groups, retrospective case-series, or summaries of registry data. Only 12 of the 32 studies [6]
Discussion
Diffuse malignant mesothelioma is a relatively rare but very insidious neoplasm associated with exposure to asbestos, typically diagnosed many years after exposure, and aggressive in its spread to local intrathoracic structures [4]. Ideally, the impact of surgery on this disease would be assessed through randomized controlled trials that compare different types of surgery or compare surgery with other treatment modalities. However, given the rarity of the disease, no controlled trials have been
Conclusions
This evidence summary report applies to adult patients with diffuse or localized malignant pleural mesothelioma. Because of the lack of sufficient high-quality evidence on the surgical management of mesothelioma, the Lung DSG opinion is that:
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The role of surgery in the management of malignant pleural mesothelioma cannot be precisely defined. Specifically, the lack of randomized controlled clinical trials makes it impossible to determine whether the use of EPP or PL improves the survival of
Acknowledgements
Sponsored by Cancer Care Ontario and the Ontario Ministry of Health and Long-term Care.
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Cited by (76)
Emerging therapies in malignant pleural mesothelioma
2019, Critical Reviews in Oncology/HematologyImpact of mesothelioma histologic subtype on outcomes in the Surveillance, Epidemiology, and End Results database
2015, Journal of Surgical ResearchCitation Excerpt :It was not possible to evaluate the utility for type of surgery received (EPP versus P/D); however, there is a lack of convincing evidence regarding the superiority for one procedure over the other. To date, the superiority of EPP over P/D has not been established, as data from randomized controlled trials are not available [15,19–22]. A retrospective analysis of 663 patients reported enhanced survival after P/D compared with EPP; however, this finding may have been confounded by selection bias [18,22].
Pleurectomy/decortication, hyperthermic pleural lavage with povidone-iodine, prophylactic radiotherapy, and systemic chemotherapy in patients with malignant pleural mesothelioma: A 10-year experience
2015, Journal of Thoracic and Cardiovascular SurgerySurgery for malignant pleural mesothelioma: Why, when and what?
2014, Lung CancerNovel Induction Therapies for Pleural Mesothelioma
2014, Seminars in Thoracic and Cardiovascular SurgeryCitation Excerpt :In recent years, the focus of studies has been either on EPP or on PD or EPD. In 2004, Maziak et al16 performed a systematic review of studies on surgical resection for mesothelioma. After reviewing the current literature, the authors concluded that there was insufficient evidence to be able to make any conclusions regarding the role of surgery in the management of mesothelioma.
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List of collaborators is included in Appendix A.