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.


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