Combined Modality Treatment in Mesothelioma

A Systemic Literature Review With Treatment Recommendations

Charlotte De Bondt; Ioannis Psallidas; Paul E. Y. Van Schil; Jan P. van Meerbeeck

Disclosures

Transl Lung Cancer Res. 2018;7(5) 

In This Article

PICO 3: What Is the Optimal Sequence of Combined Modality?

Neo-adjuvant vs. Adjuvant CT

Advocates for neoadjuvant CT claim a better tolerance, compliance and resectability with this approach.[22,26,28,29] In their retrospective series, Sharkey et al. however, did not find a difference in overall survival between the adjuvant CT group and the neo-adjuvant CT group.[18]

Cao et al. reported a median overall survival of 23.1 months in the adjuvant CT group versus 27.8 in the neo-adjuvant CT group.[32] Important to note here is that overall survival was estimated from different starting points in the different trials, which undoubtedly affects the entire analysis. Also, the trials assessing adjuvant CT are older than the neo-adjuvant series and -with one exception- all of retrospective nature. The adjuvant CT regimens differed between the trials so comparing them as a group to the more homogenous neo-adjuvant CT trials is presumptuous.

In conclusion, both approaches are defendable. The European Organization for the Research and Treatment of Cancer (EORTC) is currently enrolling (cT1–3 N0–2 M0) patients for its 1205 trial wherein they are randomized to P/D, preceded or followed by 4 cycles of platinum-pemetrexed.

Pre-op vs. Post-op RT

Cho et al. sought to reduce disease relapse—thought to be caused by tumor soiling during EPP—by implementing a short course of IMRT prior to EPP. Ideally, both a direct tumoricidal effect and a distal immunomodulating or abscopal effect are generated to prevent tumor growth in distant sites. Neoadjuvant RT was well tolerated, without severe toxicity or mortality. After five years, only one out of 9 patients with epithelioid histology and no N2 involvement had relapsed.[39] De Perrot et al. confirmed these results in the prospective SMART trial with an encouraging median survival of 36 months.

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