Elsevier

Lung Cancer

Volume 48, Issue 2, May 2005, Pages 157-169
Lung Cancer

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

https://doi.org/10.1016/j.lungcan.2004.11.003Get rights and content

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.

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:

  • 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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    List of collaborators is included in Appendix A.

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