Surgery for pleural mesothelioma
Surgery for pleural mesothelioma
A small proportion of people with pleural mesothelioma have limited disease (as seen on CT scanning), but a very large question that looms in their minds (and that of their clinicians) is whether surgery would be beneficial to help them live longer?
Whilst there are good results of surgery published by individual surgeons and institutions[1], the selection of patients with only a small amount of disease is the most important predictor of better survival. Without an equally good group with limited disease who did not receive surgery to compare with we cannot determine if the good outcomes are due to selecting patients who have a better outlook from the start for surgery. Therefore, the most reliable answers come from clinical trials with comparable groups (with equally good prospects) receiving surgery and no surgery (by chance).
There are three principal operations for pleural mesothelioma removing a large. moderate and small amount of tissue:
The large operation is called extra-pleural pneumonectomy and was evaluated in the MARS trial[2] in the UK reported that it did not improve survival - in fact participants who received the big operation that removed the whole lung, lining of the heart, the diaphragm and lining of the chest wall had worse survival and poorer quality of life. There is some uncertainty about this finding as the study stopped early and a number of surgeons around the world have challenged the certainty of a conclusion from a clinical trial that was smaller than planned.
The medium operation is called pleurectomy decortication where the lining of the lung and chest wall is removed with (if necessary) lining of the heart and/or diaphragm (if it is involved by mesothelioma). This procedure is currently being evaluated in the UK in a multicenter trial called MARS 2[3] that is expected to report in 2023.
The small operation is called partial pleurectomy where part of the diseased lining of the lung and/or chest wall is removed. MesoVATS [4] evaluated this procedure in a multicenter clinical trial in the UK and confirmed that this operation did not improve survival.
In summary, clinical trials to date have not demonstrated any improvement in survival by attempts to surgically remove pleural mesothelioma with the results from MARS 2 (the final trial of this series) expected in 2023.
The author Professor Eric Lim, is the Chief Investigator of MARS 2, a multicenter UK trial of pleurectomy decortication versus no surgery for malignant pleural mesothelioma.
References
[1] Cho BCJ, Donahoe L, Bradbury PA, Leighl N, Keshavjee S, Hope A, Pal P, Cabanero M, Czarnecka K, McRae K, Tsao M-S and de Perrot M. Surgery for malignant pleural mesothelioma after radiotherapy (SMART): final results from a single-centre, phase 2 trial. The Lancet Oncology. 2021;22:190-197.
[2] Treasure T, Lang-Lazdunski L, Waller D, Bliss JM, Tan C, Entwisle J, Snee M, O'Brien M, Thomas G, Senan S, O'Byrne K, Kilburn LS, Spicer J, Landau D, Edwards J, Coombes G, Darlison L and Peto J. Extra-pleural pneumonectomy versus no extra-pleural pneumonectomy for patients with malignant pleural mesothelioma: clinical outcomes of the Mesothelioma and Radical Surgery (MARS) randomised feasibility study. Lancet Oncol. 2011;12:763-772.
[3] Lim E, Darlison L, Edwards J, Elliott D, Fennell DA, Popat S, Rintoul RC, Waller D, Ali C, Bille A, Fuller L, Ionescu A, Keni M, Kirk A, Koh P, Lau K, Mansy T, Maskell NA, Milton R, Muthukumar D, Pope T, Roy A, Shah R, Shamash J, Tasigiannopoulos Z, Taylor P, Treece S, Ashton K, Harris R, Joyce K, Warnes B, Mills N, Stokes EA, Rogers C and Trialists M. Mesothelioma and Radical Surgery 2 (MARS 2): protocol for a multicentre randomised trial comparing (extended) pleurectomy decortication versus no (extended) pleurectomy decortication for patients with malignant pleural mesothelioma. BMJ Open. 2020;10:e038892.
[4] Rintoul RC, Ritchie AJ, Edwards JG, Waller DA, Coonar AS, Bennett M, Lovato E, Hughes V, Fox-Rushby JA, Sharples LD and Meso VC. Efficacy and cost of video-assisted thoracoscopic partial pleurectomy versus talc pleurodesis in patients with malignant pleural mesothelioma (MesoVATS): an open-label, randomised, controlled trial. Lancet. 2014;384:1118-27.