Journal and News Scan

Should we consider mesothelioma patients surgical candidates for resection? Are we actually doing more harm than good? 

During the presidential plenary of the IASLC World Conference 2023 on Lung Cancer, Dr. Eric Lim presented the results from the first randomized control trial directly comparing extended pleurectomy decortication versus platinum and pemetrexed chemotherapy alone for the treatment of patients with mesothelioma.  

The MARS 2 (Mesothelioma and Radical Surgery) trial was conducted at a single center in the United Kingdom. A total of 169 patients were randomized to surgery plus chemotherapy and 166 to chemotherapy alone. The patients were followed for a median of 22.4 months.  

One of the hallmark findings of this study was that surgery increased the risk of death in the first 42 months by 28 percent (p=0.03.) Furthermore, there were more adverse events, increased treatment costs, and decreased median survival in the cohort undergoing surgery and chemotherapy.  

This raises the question of why thoracic surgeons should intervene in the treatment of these patients if the outcomes are indeed as above. It may be time for outdated guidelines to be updated as per the evidence base. 

Despite the findings alluding to the retirement of surgical therapy for mesothelioma, the study did not find any difference in the long-term survival between both cohorts. 

However, surgery did lead to a 3.36 times increased risk for adverse events (p<0.001) and reduced EORTC quality of life scores in global health, particularly in global health, physical, social, and role functioning. Patients who underwent surgery also reported worse symptom scores for pain, insomnia, dyspnea, loss of appetite, and financial difficulties. With the median survival of mesothelioma being 12.1 months according to these results, chemotherapy alone may be a more cost-effective and clinically beneficial treatment. 

Dr. Lim stated that changing attitudes so that the disease is considered unresectable would increase access to more effective systemic treatment to improve survival. He did face some scrutiny as the primary outcome of MARS2 was overall survival and with no difference currently reported it may be premature to be rethinking the treatment for such an aggressive thoracic malignancy.

This large-scale analysis of the National Cancer Database (NCDB) highlights some interesting trends in the current use of systemic therapy in patients with NSCLC who undergo pneumonectomy. Current practice patterns show only 12 percent of patients undergoing pneumonectomy for pathologic stage IB to IIIA received neoadjuvant therapy, 43 percent received adjuvant therapy, and 45 percent underwent surgery alone. Although this retrospective study is subject to limitations of large database analysis, including selection bias reporting only patients who received a particular therapy without reasons identified, this large difference in treatment patterns is certainly an area of potential research. In an era of rapid oncological advances with targeted therapy and immunotherapy, there seems to be a role for further systemic therapy in patients who require pneumonectomy, as the authors highlight survival benefits and downstaging of tumors to perhaps allow a lesser resection to be performed.

This paper explores the application of a novel aortic valve visualization and pressurization device to inspect the valve under physiological conditions following aortic repair. The authors report their results in a cohort of twenty-four patients.This paper explores the application of a novel aortic valve visualization and pressurization device to inspect the valve under physiological conditions following aortic repair. The authors report their results in a cohort of twenty-four patients.

This is an open access genomic study of carotid atheroma in Viennese patients with a useful extensive discussion on potential translational value of the signature of calcification, juxtaposed to sonographic diagnostics and in the quest to manage the risk of rupture of carotid atheromatous plaque. The article also has gravitas in the light of the updated ESVS guidelines in carotid disease.