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Immunotherapy, the promise for present and future of malignant pleural mesothelioma (MPM) treatment.Therapeutic Advances in Medical Oncology 2021Due to occupational asbestosis exposure, the incidence of malignant pleural mesothelioma (MPM) has continuously increased over the last 30 years, with a plateau... (Review)
Review
Due to occupational asbestosis exposure, the incidence of malignant pleural mesothelioma (MPM) has continuously increased over the last 30 years, with a plateau anticipated around the year 2030 in Western countries. Molecular MPM carcinogenesis involves alterations of NF2, RASSF1, LATS2WT1, p16, as well as BAP-1tumor-suppressor genes, which usually regulate apoptosis, cell invasion, motility, cell division, chromatin remodeling, as well as control of DNA repair. In few selected patients, debulking surgery consisting of pleurectomy-decortication is carried out, resulting in unsatisfactory long-term results. For about 15 years, first-line chemotherapy has been primarily based on a doublet of pemetrexed and cisplatin. Adding the monoclonal antibody bevacizumab (Avastin), which targets vascular endothelial growth factor (VEGF), has been shown to improve overall survival (OS) by nearly 19 months. The emergence of immune check-point inhibitors (ICIs) in MPM treatment has recently been associated with substantial survival improvements in both second- and first-line settings. Similarly to non-small-cell lung cancer (NSCLC) patients, on-going trials are presently exploring the chemotherapy-ICI combination in MPM management, and depending on their results, this combination could represent a further major advance in this previously orphan disease. The current article reviews recent clinical trial results, as well as future clinical developments in this moving field.
PubMed: 34917175
DOI: 10.1177/17588359211061956 -
Journal of Clinical Medicine Mar 2022Two-port (2P) and three-port (3P) video-assisted thoracoscopic surgery (VATS) are well-established surgical methods for the treatment of complicated spontaneous...
BACKGROUND
Two-port (2P) and three-port (3P) video-assisted thoracoscopic surgery (VATS) are well-established surgical methods for the treatment of complicated spontaneous pneumothorax (SP). However, a comparison between both techniques, in terms of clinical outcomes in patients with secondary spontaneous pneumothorax (SSP), is unreported. The aim of this study was to evaluate and compare postoperative pain, as well as clinical outcome, following 2P and 3P VATS for SSP in our institution.
METHODS
Between January 2008 and December 2020, we retrospectively analyzed the data of 115 SSP patients treated by VATS in our institution. Fifty-two patients underwent 2P-VATS, while 63 patients were treated by 3P-VATS. The total dose of analgesic use per stay (opioid and non-opioid), length of hospital stay (LOS), operation time, total area of pleurectomy, recurrence rates and postoperative complications were compared between both groups.
RESULTS
The 3P-VATS group had a significantly higher total dose of analgesic use compared with the 2P-VATS patients. The LOS and mean operation time were significantly shorter in the 2P-VATS group. A larger area of pleurectomy was resected using 3P-VATS compared to 2P-VATS. The postoperative complications and recurrence of SSP during a median follow-up period of 76.5 months were similar in both groups.
CONCLUSION
2P-VATS is a safe surgical technique. It is associated with a short LOS and less postoperative pain, and, thus, low analgesic use.
PubMed: 35268495
DOI: 10.3390/jcm11051404 -
Journal of Thoracic Disease Sep 2022Malignant pleural mesothelioma (MPM) is a rare and aggressive tumor that should be managed by an experienced surgical and multidisciplinary group. Our objective was to...
BACKGROUND
Malignant pleural mesothelioma (MPM) is a rare and aggressive tumor that should be managed by an experienced surgical and multidisciplinary group. Our objective was to determine the impact of proficient surgeons and MPM bi-disciplinary review on outcomes of patients with MPM.
METHODS
Through this cohort study, electronic medical records of 368 adult patients with MPM from 1/1/2009 to 12/31/2020 were reviewed and compared before and after MPM surgeries were regionalized to specialized surgeons and bi-disciplinary review of MPM patient treatment options. We used the Kaplan-Meier method and log-rank tests to compare survival rates by period, by treatment type, and by stage. Patients were followed from cancer diagnosis date until they died or end of study follow-up, whichever occurred first. We also conducted Cox proportional hazards regression model to examine the overall survival (OS) with adjustments for age, histology, stage, and Charlson comorbidity index (CCI).
RESULTS
Despite similar staging, more patients received any MPM directed treatment from 2015-2020 compared with those patients from 2009-2014. Specifically, there was an increase in patients who received pleurectomy/decortication (PD) from 2015-2020 compared to those who received PD in 2009-2014. Patients with similar age, CCI, stage, and histology had an increase in OS of 12 months with multimodality therapy (surgery, systemic therapy, +/- radiation) compared to those patients who received no treatment.
CONCLUSIONS
Consolidating mesothelioma surgery to a specialized surgical team and regular bi-disciplinary review of MPM cases to determine appropriate multimodality therapy, increases the incorporation of surgical treatments in the management of patients with MPM.
PubMed: 36245635
DOI: 10.21037/jtd-22-427 -
Translational Lung Cancer Research Feb 2020Extrapleural pneumonectomy (EPP) and pleurectomy decortication (PD) are radical operations for malignant pleural mesothelioma (MPM) that remain controversial among... (Review)
Review
Extrapleural pneumonectomy (EPP) and pleurectomy decortication (PD) are radical operations for malignant pleural mesothelioma (MPM) that remain controversial among thoracic surgeons. There is a lack of randomized evidence to support a survival benefit when major surgical resection is included in multi-modality treatment regimens. Current data from retrospective single institution reviews and prospective trials such as the Surgery for Mesothelioma After Radiation Therapy (SMART) trial are limited by biased patient selection to include only the healthiest patients with most limited disease burden. This patient population predictably has relatively longer survival times than patients with inoperable advanced disease. The only randomized trial to date that has objectively evaluated the true benefit of surgical resection was the Mesothelioma and Radical Surgery (MARS) trial which actually showed shorter survival times among patients who underwent EPP compared with those treated medically. Critics of the MARS trial cite a high perioperative mortality rate for driving these results, however a similar trial has never been repeated to refute the MARS trial results. Finally, it is relevant to consider the high mortality and morbidity rates associated with major operations when recommending these interventions to MPM patients. There is a growing body of literature that identifies patients who clearly obtain no benefit from surgery including those with sarcomatoid or biphasic histology, nodal disease, elevated CRP, elevated platelets and advanced age. Surgery in MPM has risks and is of questionable benefit with outcomes data biased by patient selection of those who will have longer overall survival times regardless of treatment.
PubMed: 32206574
DOI: 10.21037/tlcr.2020.01.08 -
Journal of Cardiothoracic Surgery Jun 2024Multiportal video-assisted thoracic surgery (mVATS) is the standard approach for the surgical treatment of spontaneous pneumothorax. However, uniportal VATS (uVATS) has... (Comparative Study)
Comparative Study
BACKGROUND
Multiportal video-assisted thoracic surgery (mVATS) is the standard approach for the surgical treatment of spontaneous pneumothorax. However, uniportal VATS (uVATS) has emerged as an alternative aiming to minimize surgical morbidity. This study aims to strengthen the evidence on the safety and efficiency of uVATS compared to mVATS.
METHODS
From January 2004 to December 2020, records of patients who had undergone surgical treatment for primary or secondary spontaneous pneumothorax were evaluated for eligibility. Patients who had undergone pleurectomy combined with bullectomy or apical wedge resection via uVATS or mVATS were included. Surgical characteristics and postoperative data were compared between patients who had undergone surgery via uVATS or mVATS. Univariable and multivariable analyses were performed to determine whether the surgical approach was associated with any complication (primary outcome), major complications (i.e., Clavien-Dindo ≥ 3), recurrence, prolonged hospitalization or prolonged chest drainage duration (secondary outcomes).
RESULTS
A total of 212 patients were enrolled. Patients treated via uVATS (n = 71) and mVATS (n = 141) were significantly different in pneumothorax type (secondary spontaneous; uVATS: 54 [76%], mVATS: 79 [56%]; p = 0.004). No significant differences were observed in (major) complications and recurrence rates between both groups. Multivariable analyses revealed that the surgical approach was no significant predictor for the primary or secondary outcomes.
CONCLUSIONS
This study indicates that uVATS is non-inferior to mVATS in the surgical treatment of spontaneous pneumothorax regarding safety and efficiency, and thus the uVATS approach has the potential for further improvements in the perioperative surgical care for spontaneous pneumothorax.
Topics: Humans; Pneumothorax; Thoracic Surgery, Video-Assisted; Male; Female; Adult; Retrospective Studies; Treatment Outcome; Postoperative Complications; Middle Aged
PubMed: 38926766
DOI: 10.1186/s13019-024-02931-4 -
Cancer Imaging : the Official... Aug 2021Tumor thickness and tumor volume measured by computed tomography (CT) were suggested as valuable prognosticator for patients' survival diagnosed with malignant pleural...
OBJECTIVES
Tumor thickness and tumor volume measured by computed tomography (CT) were suggested as valuable prognosticator for patients' survival diagnosed with malignant pleural mesothelioma (MPM). The purpose was to assess the accuracy of CT scan based preoperatively measured tumor volume and thickness compared to actual tumor weight of resected MPM specimen and pathologically assessed tumor thickness, as well as an analysis of their impact on overall survival (OS).
METHODS
Between 09/2013-08/2018, 74 patients were treated with induction chemotherapy followed by (extended) pleurectomy/decortication ((E)PD). In 53 patients, correlations were made between CT-measured volume and -tumor thickness (cTV and cTT) and actual tumor weight (pTW) based on the available values. Further cTV and pT/IMIG stage were correlated using Pearson correlation. Overall survival (OS) was calculated with Kaplan Meier analysis and tested with log rank test. For correlation with OS Kaplan-Meier curves were made and log rank test was performed for all measurements dichotomized at the median.
RESULTS
Median pathological tumor volume (pTV) and pTW were 530 ml [130 ml - 1000 ml] and 485 mg [95 g - 982 g] respectively. Median (IQR) cTV was 77.2 ml (35.0-238.0), median cTT was 9.0 mm (6.2-13.7). Significant association was found between cTV and pTV (R = 0.47, p < 0.001) and between cTT and IMIG stage (p = 0,001) at univariate analysis. Multivariate regression analysis revealed, that only cTV correlates with pTV. Median follow-up time was 36.3 months with 30 patients dead at the time of the analysis. Median OS was 23.7 months. 1-year and 3-year survival were 90 and 26% respectively and only the cTV remained statistically associated with OS.
CONCLUSION
Preoperatively assessed CT tumor volume and actual tumor volume showed a significant correlation. CT tumor volume may predict pathological tumor volume as a reflection of tumor burden, which supports the integration of CT tumor volume into future staging systems.
Topics: Humans; Lung Neoplasms; Male; Mesothelioma; Mesothelioma, Malignant; Neoplasm Staging; Tomography, X-Ray Computed; Treatment Outcome; Tumor Burden
PubMed: 34344472
DOI: 10.1186/s40644-021-00415-5 -
Indian Journal of Surgical Oncology Dec 2021This study was aimed at evaluating the safety and efficacy of hyperthermic intrathoracic chemotherapy in patients with Masaoka stage IVA thymoma. This is a retrospective...
This study was aimed at evaluating the safety and efficacy of hyperthermic intrathoracic chemotherapy in patients with Masaoka stage IVA thymoma. This is a retrospective comparative analysis between two groups of patients who were operated for Masaoka stage IVA thymoma. One group underwent complete parietal pleurectomy whereas other group received hyperthermic intrathoracic chemotherapy after complete pleurectomy. An analysis of all perioperative variables, complications and survival was carried out. A total of 13 patients had stage IVA disease during the study period. Initial 7 patients (March 2012-March 2015) underwent complete parietal pleurectomy, whereas next 6 patients (April 2015-December 2018) had undergone HITHOC after complete parietal pleurectomy. Both groups are comparable in terms of age, co-morbidities, tumor size and duration of symptoms. The duration of surgery and intra-operative blood loss, postoperative ICU stay, duration of ICD and total hospital stay was similar between two groups. The total number of post-operative complications was higher in HITHOC group (5 vs 2), however non-significant ( = 0.10). The median follow-up duration was 63 months in no HITHOC group and 49.5 months in HITHOC group. There was no peri-operative mortality. The overall survival ( = 0.06) and relapse-free survival ( = 0.36) were not significantly different in the both groups. Hyperthermic intrathoracic chemotherapy is a safe and feasible modality with no added morbidity or mortality. Multi-institutional prospective studies with large number of patients are required to accurately assess survival benefit.
PubMed: 35110910
DOI: 10.1007/s13193-021-01430-5 -
Journal of Pediatric Surgery Jan 2021Surgical indications and techniques have changed over the last 15 years. The number of Pediatric Surgery training programs has also increased. We sought to examine the...
BACKGROUND/PURPOSE
Surgical indications and techniques have changed over the last 15 years. The number of Pediatric Surgery training programs has also increased. We sought to examine the effect of these changes on resident education by examining case log data.
METHODS
Accreditation Council for Graduate Medical Education (ACGME) case logs for graduating Pediatric Surgery residents were examined from 2004 to 2018. Using the summary statistics provided, linear regression analysis was conducted on each case log code and category.
RESULTS
In 2004, there were 24 Pediatric Surgery training programs and 24 Pediatric Surgery residents graduating with an average of 979.8 total cases logged. In 2018, there were 36 programs with 38 residents graduating with an average of 1260.2 total cases logged. Total case volume of graduating residents significantly increased over the last 15 years (p < 0.001). Significant increases were demonstrated in skin/soft tissue/musculoskeletal (p < 0.01), abdominal (p < 0.001), hernia repair (p < 0.001), genitourinary (p < 0.01), and endoscopy (p < 0.001). No significant changes were seen in the head and neck, thoracic, cardiovascular, liver/biliary, and non-operative trauma categories. No categories significantly decreased over the time period. No significant changes were seen in the number of multiple index congenital cases, including tracheoesophageal fistula/esophageal atresia repair, omphalocele, gastroschisis, choledochal cyst excision, perineal procedure for imperforate anus, and major hepatic resections for tumors. Pertinent increases in specific procedures include diaphragmatic hernia repair (p < 0.01), ECMO cannulation/decannulation(p < 0.05), thyroidectomy (p < 0.001), parathyroidectomy (p < 0.001), biliary atresia (p < 0.001), and circumcision (p < 0.001) as well as most laparoscopic abdominal procedures. Specific procedure codes with significant decreases include tracheostomy (p < 0.05), minimally invasive decortication/pleurectomy/blebectomy (p < 0.001), laparoscopic splenectomy (p < 0.001), as well as most open abdominal procedures.
CONCLUSION
Despite increasing numbers of Pediatric Surgery residents and training programs, the number of cases performed by each graduating resident has increased. This increase is primarily fueled by increase in abdominal, skin/soft tissue/musculoskeletal, hernia repair, genitourinary, and endoscopic cases.
LEVEL OF EVIDENCE
Level II.
Topics: Accreditation; Child; Clinical Competence; Education, Medical, Graduate; General Surgery; Humans; Internship and Residency; Male; Retrospective Studies; United States; Workload
PubMed: 33139026
DOI: 10.1016/j.jpedsurg.2020.09.038 -
The Thoracic and Cardiovascular Surgeon Sep 2023Complexities in TNM staging in epithelioid malignant pleural mesothelioma (MPM) may lead to errors in treatment selection, leading to major surgical interventions in...
BACKGROUND
Complexities in TNM staging in epithelioid malignant pleural mesothelioma (MPM) may lead to errors in treatment selection, leading to major surgical interventions in patients with low survival expectations.
METHODS
Sixty-nine stage I epithelioid MPM patients, including 27 patients treated with pleurectomy/decortication (P/D) and multimodal therapy (MMT) (the P/D [MMT] group), and 42 patients treated with chemotherapy or chemoradiotherapy (the CRT group), were included in the study. After an initial evaluation of overall survival, all patients were grouped in terms of histopathological parameters and treatment types, and then, a secondary survival evaluation was performed for the groups.
RESULTS
Forty-one patients were male, the mean age was 61.8 years. The median survival time was 26 months in the P/D (MMT) group, and 19.6 months in the CRT group, but the difference was not statistically significant. After grouping according to pathological criteria, a median survival time of 32.4 ± 2.9 months in the P/D (MMT) group and 21.9 ± 3.2 months in the CRT group was obtained among patients with histopathological low-grade tumors. Among patients with high-grade tumors, the median survival time was 18.3 ± 2.6 months in the P/D (MMT) group and 17 ± 4.4 months in the CRT group. Among patients with low-grade tumors, the P/D (MMT) group had longer survival. Median survival times were similar among patients with high-grade tumors.
CONCLUSION
In epithelioid MPM, histopathological grading by video-assisted thoracic surgery pleural biopsy can prove accurate in selecting patients for P/D and MMT.
Topics: Humans; Male; Middle Aged; Female; Mesothelioma, Malignant; Mesothelioma; Patient Selection; Pleural Neoplasms; Lung Neoplasms; Treatment Outcome
PubMed: 36736368
DOI: 10.1055/s-0043-1761209 -
Translational Lung Cancer Research Feb 2023
PubMed: 36895923
DOI: 10.21037/tlcr-23-24