Treatment of malignant pleural mesothelioma with chemotherapy preceding versus after surgical resection

Vivek Verma; Christopher A Ahern; Christopher G Berlind; William D Lindsay; Surbhi Grover; Joseph S Friedberg; Charles B Simone 2nd

doi:10.1016/j.jtcvs.2018.10.039

Treatment of malignant pleural mesothelioma with chemotherapy preceding versus after surgical resection

J Thorac Cardiovasc Surg. 2019 Feb;157(2):758-766.e1. doi: 10.1016/j.jtcvs.2018.10.039. Epub 2018 Oct 22.

Authors

Vivek Verma¹, Christopher A Ahern², Christopher G Berlind², William D Lindsay², Surbhi Grover³, Joseph S Friedberg⁴, Charles B Simone 2nd⁵

Affiliations

¹ Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, Pa.
² Oncora Medical, Philadelphia, Pa.
³ Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pa.
⁴ Division of Thoracic Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, Md.
⁵ Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Md. Electronic address: charlessimone@umm.edu.

PMID: 30454981
DOI: 10.1016/j.jtcvs.2018.10.039

Abstract

Objectives: There are 2 main treatment paradigms recognized by the National Comprehensive Cancer Network for resectable malignant pleural mesothelioma (MPM): induction chemotherapy followed by resection (IC/R), and up-front resection with postoperative chemotherapy (R/PC). These paradigms are being compared in an accruing randomized phase II trial. In the absence of such completed trials, in this study we evaluated overall survival (OS) and postoperative outcomes of IC/R and R/PC.

Methods: The National Cancer Database was queried for newly diagnosed epithelioid/biphasic MPM. Metastatic, node-positive, and/or cT4 disease was excluded, along with nondefinitive surgery and lack of chemotherapy. Multivariable logistic regression ascertained factors independently associated with induction chemotherapy delivery. Kaplan-Meier analysis was used to evaluate OS between cohorts; multivariable Cox proportional hazards modeling was used to assess factors associated with OS. Survival was also evaluated between propensity-matched populations. Last, postoperative outcomes were assessed between groups.

Results: Overall, 361 patients (182 IC/R, 179 R/PC) were analyzed. Temporal trends revealed that IC/R is decreasing over time. Survival of the IC/R cohort was similar to that of R/PC patients (20.9 vs 21.7 months; P = .500); this persisted after propensity matching (20.8 vs 22.0 months; P = .270). However, patients who underwent IC/R experienced longer postoperative hospitalization (median 7 days vs 6 days; P = .001) and higher 30-day mortality (3.3% vs 0%; P = .020).

Conclusions: To our knowledge, this is the only comparative investigation of the 2 major management paradigms of operable MPM. IC/R regimens are decreasing over time in the United States. Although associated with survival similar to R/PC, IC/R might be associated with worse postoperative outcomes. Careful induction chemotherapy patient selection is thus highly recommended.

Keywords: biphasic; chemotherapy; epithelioid; mesothelioma; pleural; surgery.

Publication types

Comparative Study
Video-Audio Media

MeSH terms

Aged
Chemotherapy, Adjuvant
Clinical Decision-Making
Databases, Factual
Female
Humans
Lung Neoplasms / mortality
Lung Neoplasms / pathology
Lung Neoplasms / therapy*
Male
Mesothelioma / mortality
Mesothelioma / pathology
Mesothelioma / therapy*
Mesothelioma, Malignant
Middle Aged
Neoadjuvant Therapy* / adverse effects
Neoadjuvant Therapy* / mortality
Neoadjuvant Therapy* / trends
Patient Selection
Pleural Neoplasms / mortality
Pleural Neoplasms / pathology
Pleural Neoplasms / therapy*
Retrospective Studies
Risk Assessment
Risk Factors
Thoracic Surgical Procedures* / adverse effects
Thoracic Surgical Procedures* / mortality
Thoracic Surgical Procedures* / trends
Time Factors
Treatment Outcome
United States