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EPP No, Chemotherapy Yes, Suggests New Mesothelioma Study
A pair of thoracic oncologists from Belgium say it's time to go a step further in the wake of a controversial study on mesothelioma surgery and examine the impact of perioperative chemotherapy.
Based on mesothelioma research from around the world, the 2011 Mesothelioma and Radical Surgery (MARS) randomized feasibility study concluded that extrapleural pneumonectomy (EPP) was too risky and should be abandoned as a surgical approach for mesothelioma. EPP involves removing not only the diseased pleura containing the mesothelioma tumor, but also the nearest lung, the diaphragm, and other internal membranes. The MARS study recommended, instead, that operable mesothelioma be treated with lung-sparing pleurectomy/decortication (P/D) or extended pleurectomy/decortication.
But surgery alone, regardless of which method is used, has been shown to produce only "modest outcomes" in the treatment of mesothelioma. Most patients also need perioperative chemotherapy to kill remaining mesothelioma cells and keep the disease from returning or progressing. (Perioperative refers to the time before, during and after surgery from hospital admission to discharge.) Given this fact, as well as the MARS data, a new article in the Journal of Thoracic Oncology says the European Organisation for Research and Treatment of Cancer will launch a trial specifically exploring the feasibility and effectiveness of chemotherapy with pleurectomy/decortication.
"The observation that patients treated with P/D had an equal to better outcome than those treated with EPP, and that EPP with perioperative chemotherapy was better than EPP alone, raises the issue whether performing a P/D with perioperative chemotherapy would result in a further improvement of outcome with a lower operative mortality than with EPP and perioperative chemotherapy," write the Antwerp-based authors.
While the article does not suggest which chemotherapy combination would be used for such a trial, new research out of Egypt suggests that different chemotherapy regimens may be used for different stages of mesothelioma. A Phase II study conducted at the Cairo University School of Medicine found that mesothelioma outcomes could be considered comparable between patients who received a combination of the drugs pemetrexed and carboplatin and those who received a less expensive combination of gemcitabine and cisplatin if their disease stage was also taken into consideration.
The pemetrexed/carboplatin group showed a cumulative survival at 1.5 years of 57.8% as compared to 41% for the gemcitabine/cisplatin group, but the researchers say this difference would have little impact in the advanced stages of mesothelioma, given the aggressiveness of the disease. They write, "Pemetrexed plus carboplatin are a step forward in the treatment of mesothelioma, [but] the prognosis for these patients remains poor. Cheaper combinations such as gemcitabine and cisplatin may be considered sufficient to treat cases with advanced mesothelioma."
Hiddinga, BI, van Meerbeeck, JP, "Surgery in Mesothelioma: Where do we go after MARS?", February 12, 2013, Journal of Thoracic Oncology, Epub ahead of print.
Habib, EE, Fahmy, ES, "Chemotherapy management of malignant pleural mesothelioma: a phase II study comparing two popular chemotherapy regimens", February 14, 2013, Clinical & Translational Oncology, Epub ahead of print.