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Current Opinion in Oncology Jan 2021Malignant pleural mesothelioma (MPM) is a rare, but aggressive tumor with still poor prognosis. In this article, we focus on recent developments in the management of MPM... (Review)
Review
PURPOSE OF REVIEW
Malignant pleural mesothelioma (MPM) is a rare, but aggressive tumor with still poor prognosis. In this article, we focus on recent developments in the management of MPM including diagnosis, staging, biomarkers, and treatment strategies.
RECENT FINDINGS
Molecular markers such as programmed death-ligand 1 (PDL-1), Breast Cancer gene 1-associated protein gene, and cyclin-dependent kinase inhibitor 2A (CDKN2A) have prognostic impact and should be considered for assessment in patient samples. In addition to histological subtype and tumor pattern, tumor volumetry plays an increasing important role in staging, assessment of treatment response, and prediction of survival. Several new blood-based biomarkers have been recently reported including peripheral blood DNA methylation, microRNAs, fibulin, and high-mobility group box 1, but have not been established in clinical routine use yet. Regarding treatment, targeted therapies, immunotherapy, and vaccination are considered as new promising strategies. Moreover, extended pleurectomy/decortication is favored over extrapleural pneumonectomy (EPP) and intensity-modulated radiotherapy represents a possible approach in combination with EPP and pleurectomy/decortication. Intracavitary treatment options are promising and deserve further investigations.
SUMMARY
Overall, there has not been a real breakthrough in the treatment of MPM. Further research and clinical trials are needed to evaluate outcome and to identify new potential treatment candidates.
Topics: Clinical Trials, Phase II as Topic; Clinical Trials, Phase III as Topic; Combined Modality Therapy; Humans; Mesothelioma, Malignant; Neoplasm Staging; Pleural Neoplasms; Randomized Controlled Trials as Topic
PubMed: 33186182
DOI: 10.1097/CCO.0000000000000697 -
BMJ Open Sep 2020Mesothelioma remains a lethal cancer. To date, systemic therapy with pemetrexed and a platinum drug remains the only licensed standard of care. As the median survival...
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.
INTRODUCTION
Mesothelioma remains a lethal cancer. To date, systemic therapy with pemetrexed and a platinum drug remains the only licensed standard of care. As the median survival for patients with mesothelioma is 12.1 months, surgery is an important consideration to improve survival and/or quality of life. Currently, only two surgical trials have been performed which found that neither extensive (extra-pleural pneumonectomy) or limited (partial pleurectomy) surgery improved survival (although there was some evidence of improved quality of life). Therefore, clinicians are now looking to evaluate pleurectomy decortication, the only radical treatment option left.
METHODS AND ANALYSIS
The MARS 2 study is a UK multicentre open parallel group randomised controlled trial comparing the effectiveness and cost-effectiveness of surgery-(extended) pleurectomy decortication-versus no surgery for the treatment of pleural mesothelioma. The study will test the hypothesis that surgery and chemotherapy is superior to chemotherapy alone with respect to overall survival. Secondary outcomes include health-related quality of life, progression-free survival, measures of safety (adverse events) and resource use to 2 years. The QuinteT Recruitment Intervention is integrated into the trial to optimise recruitment.
ETHICS AND DISSEMINATION
Research ethics approval was granted by London - Camberwell St. Giles Research Ethics Committee (reference 13/LO/1481) on 7 November 2013. We will submit the results for publication in a peer-reviewed journal.
TRIAL REGISTRATION NUMBERS
ISRCTN-ISRCTN44351742 and ClinicalTrials.gov-NCT02040272.
Topics: Humans; London; Lung Neoplasms; Mesothelioma; Mesothelioma, Malignant; Multicenter Studies as Topic; Pleural Neoplasms; Quality of Life; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 32873681
DOI: 10.1136/bmjopen-2020-038892 -
Annals of the Royal College of Surgeons... Apr 2022Thoracic endometriosis syndrome is an under-recognised manifestation of endometriosis and includes catamenial pneumothorax, catamenial haemothorax, catamenial...
Thoracic endometriosis syndrome is an under-recognised manifestation of endometriosis and includes catamenial pneumothorax, catamenial haemothorax, catamenial haemoptysis and pulmonary nodules. Catamenial pneumothorax presents as recurrent spontaneous pneumothorax with a temporal relationship to the onset of menses, affecting mostly the right lung. A 48-year-old woman presented with an eight-year history of right-sided catamenial pneumothorax, during which time she had three episodes of pneumothorax. Serial chest imaging revealed an enlarging mass overlying the right hemi-diaphragm. She was referred to our trust where she underwent video-assisted thoracoscopic surgery for right pleurectomy. Intraoperatively, defects were found in the right hemidiaphragm, through which parts of the liver had herniated. We describe the presenting features and management of catamenial pneumothorax.
Topics: Diaphragm; Endometriosis; Female; Humans; Middle Aged; Pneumothorax; Thoracic Surgery, Video-Assisted
PubMed: 34825583
DOI: 10.1308/rcsann.2021.0164 -
European Journal of Cardio-thoracic... Jul 2020One of the potential disadvantages of conventional pleurectomy/decortication for malignant pleural mesothelioma is the need for opening the pleural sac, which might...
One of the potential disadvantages of conventional pleurectomy/decortication for malignant pleural mesothelioma is the need for opening the pleural sac, which might worsen survival. In this study, we have introduced non-incisional pleurectomy/decortication as an alternative technique that does not require the opening of the pleural sac.
Topics: Humans; Mesothelioma; Pleural Neoplasms; Thoracic Surgical Procedures; Time Factors; Treatment Outcome
PubMed: 32011679
DOI: 10.1093/ejcts/ezaa012 -
Turk Gogus Kalp Damar Cerrahisi Dergisi Oct 2021Minimally invasive repair of pectus excavatum (Nuss) operation is the current choice of surgical treatment for pectus excavatum deformities. Technical pitfalls arise in...
Minimally invasive repair of pectus excavatum (Nuss) operation is the current choice of surgical treatment for pectus excavatum deformities. Technical pitfalls arise in patients with previous thoracic and/or cardiac surgical interventions, due to severe intrathoracic fibrous adhesions. Herein, we describe an original modification technique in a patient with bilateral apical wedge resection and total pleurectomy due to recurrent spontaneous pneumothorax episodes within the past two years. Correction was performed by opening the pleura bilaterally and retrosternal release with digital palpation via a subxiphoid incision, to help to guide the introducer and the pectus bar, without a videothoracoscopic visualization.
PubMed: 35096458
DOI: 10.5606/tgkdc.dergisi.2021.21092 -
BMJ Open May 2024Extrapleural pneumonectomy (EPP) and extended pleurectomy/decortication (ePD) are surgical cytoreductive techniques aimed at achieving macroscopic resection in malignant... (Review)
Review
INTRODUCTION
Extrapleural pneumonectomy (EPP) and extended pleurectomy/decortication (ePD) are surgical cytoreductive techniques aimed at achieving macroscopic resection in malignant pleural tumours such as pleural mesothelioma, non-mesothelioma pleural malignancies such as thymoma and sarcoma, and rarely for pleural tuberculosis, in a more limited fashion. Despite extensive studies on both surgical techniques and consequences, a significant knowledge gap remains regarding how best to approach the perioperative anaesthesia challenges for EPP and ePD.It is unknown if the risk stratification processes for such surgeries are standardised or what types of functional and dynamic cardiac and pulmonary tests are employed preoperatively to assist in the perioperative risk stratification. Further, it is unknown whether the types of anaesthesia and analgesia techniques employed, and the types of haemodynamic monitoring tools used, impact on outcomes. It is also unknown whether individualised haemodynamic protocols are used to guide the rational use of fluids, vasoactive drugs and inotropes.Finally, there is a dearth of evidence regarding how best to monitor these patients postoperatively or what the most effective enhanced recovery protocols are to best mitigate postoperative complications and accelerate hospital discharge. To increase our knowledge of the perioperative and anaesthetic treatment for patients undergoing EPP/ePD, this scoping review attempts to synthesise the literature and identify these knowledge gaps.
METHODS AND ANALYSIS
This scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Review Protocols methodology. Electronic databases, OVID Medline, EMBASE and the Cochrane Library, will be systematically searched for relevant literature corresponding to EPP or ePD and perioperative or anaesthetic management. Data will be analysed and summarised descriptively and organised according to the three perioperative stages: preoperative, intraoperative and postoperative factors in clinical care.
ETHICS AND DISSEMINATION
Ethics approval was not required. The findings will be disseminated through professional networks, conference presentations and publications in scientific journals.
Topics: Humans; Pneumonectomy; Anesthesia; Pleura; Perioperative Care; Pleural Neoplasms; Postoperative Complications
PubMed: 38760041
DOI: 10.1136/bmjopen-2023-078125 -
Cancers Apr 2024Surgery plays a central role in the diagnosis, staging, and management of pleural mesothelioma. Achieving an accurate diagnosis through surgical intervention and... (Review)
Review
Surgery plays a central role in the diagnosis, staging, and management of pleural mesothelioma. Achieving an accurate diagnosis through surgical intervention and identifying the specific histologic subtype is crucial for determining the appropriate course of treatment. The histologic subtype guides decisions regarding the use of chemotherapy, immunotherapy, or multimodality treatment. The goal of surgery as part of multimodality treatment is to accomplish macroscopic complete resection with the eradication of grossly visible and palpable disease. Over the past two decades, many medical centers worldwide have shifted from performing extra-pleural pneumonectomy (EPP) to pleurectomy decortication (PD). This transition is motivated by the lower rates of short-term mortality and morbidity associated with PD and similar or even better long-term survival outcomes, compared to EPP. This review aims to outline the role of surgery in diagnosing, staging, and treating patients with pleural mesothelioma.
PubMed: 38730667
DOI: 10.3390/cancers16091719 -
General Thoracic and Cardiovascular... Sep 2021Pleurectomy/decortication has been preferably employed as a curative-intent surgery for malignant pleural mesothelioma. However, visceral pleurectomy during...
OBJECTIVE
Pleurectomy/decortication has been preferably employed as a curative-intent surgery for malignant pleural mesothelioma. However, visceral pleurectomy during pleurectomy/decortication provides technical challenges. For visceral pleurectomy, pleural incisions are commonly made to create a dissection plane between the visceral pleura and the lung parenchyma, which may cause tumor dissemination and may not allow en bloc complete resection of the entire pleura. To overcome such potential disadvantages, we have developed a novel surgical technique without any pleural incision (non-incisional pleurectomy/decortication) to achieve en bloc removal of the entire pleura.
METHODS
A total of 36 consecutive patients who underwent non-incisional pleurectomy/decortication for malignant pleural mesothelioma from January 2017 through December 2020 in our institute were retrospectively reviewed to assess the feasibility.
RESULTS
Macroscopic complete resection was achieved in 31 patients (86.1%) with non-incisional pleurectomy/decortication. In the majority of patients (n = 29), en bloc complete resection of the entire pleura was achieved (without pleural laceration in 10 and with some pleural laceration in 19 patients). The total operation time and the duration of visceral pleurectomy were significantly shorter as compared with those for conventional pleurectomy/decortication (median, 350 versus 506 min [P = 0.011], and 43 versus 97 min [P < 0.001], respectively). Among 36 patients who underwent non-incisional pleurectomy/decortication, postoperative complications developed in 13 patients (36.1%), and one patient died on the postoperative day 95 caused by aggressive tumor progression of residual tumor.
CONCLUSIONS
Non-incisional pleurectomy/decortication is a fast and feasible technique to achieve en bloc macroscopic complete resection for malignant pleural mesothelioma.
Topics: Humans; Lung Neoplasms; Mesothelioma; Mesothelioma, Malignant; Pleura; Pleural Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 34028663
DOI: 10.1007/s11748-021-01643-z -
Thoracic Surgery Clinics Nov 2020Extended pleurectomy and decortication (ePD) is a difficult operation performed for the surgical resection of malignant pleural mesothelioma that can achieve a... (Review)
Review
Extended pleurectomy and decortication (ePD) is a difficult operation performed for the surgical resection of malignant pleural mesothelioma that can achieve a macroscopic complete resection with preservation of the lung. With lower perioperative mortality, similar long-term survival, and better tolerance in patients with lower performance status, ePD has become the preferred operation rather than extrapleural pneumonectomy despite lack of a direct comparison. As ePD has become more popular, international collaboration is underway to create surgical guidelines based on collection of operative data. These efforts will improve the safety and standardization of this operation.
Topics: Humans; Mesothelioma, Malignant; Pleura; Pleural Neoplasms; Thoracic Surgical Procedures; Treatment Outcome
PubMed: 33012432
DOI: 10.1016/j.thorsurg.2020.07.002 -
Expert Review of Respiratory Medicine Dec 2019: The surgical arm of the Mesothelioma and Radical Surgery (MARS) trial involved a multimodal approach, with combined therapy consisting of chemotherapy, complete gross... (Review)
Review
: The surgical arm of the Mesothelioma and Radical Surgery (MARS) trial involved a multimodal approach, with combined therapy consisting of chemotherapy, complete gross resection, and radiation therapy. However, the MARS trial did not compare surgery with chemotherapy, and the survival and quality of life outcomes of this trial's surgical arm were inferior to those of the non-surgical arm. Methods for achieving complete gross resection (macroscopic complete response [MCR]) include extrapleural pneumonectomy (EPP), wherein the pleura, lung, diaphragm, and pericardium are removed en bloc, and pleurectomy/decortication (P/D), wherein the affected lung is preserved. Nonetheless, the most effective therapy remains unclear.: Here, surgery post-neoadjuvant chemotherapy for malignant pleural mesothelioma with either EPP or P/D has been discussed, along with trimodal and bimodal therapies.: With the development of post-P/D radiation therapy, it is currently possible to truly compare EPP with P/D. Moreover, R0 resection cannot be achieved with either EPP or P/D; thus, both must incorporate debulking, although the two procedures are largely incompatible. Therefore, there is a need to rebuild the status of surgery as a multimodal therapy.
Topics: Combined Modality Therapy; Humans; Mesothelioma; Neoadjuvant Therapy; Pleural Neoplasms; Pneumonectomy; Quality of Life; Thoracic Surgical Procedures; Treatment Outcome
PubMed: 31596628
DOI: 10.1080/17476348.2019.1679119