ArticlesEfficacy and cost of video-assisted thoracoscopic partial pleurectomy versus talc pleurodesis in patients with malignant pleural mesothelioma (MesoVATS): an open-label, randomised, controlled trial
Introduction
The incidence of malignant pleural mesothelioma continues to rise;1, 2, 3 however, few evidence-based therapeutic options are available. Cisplatin plus pemetrexed chemotherapy has been shown to confer a slight survival advantage.4, 5 The role of surgical resection is uncertain, but several operative approaches have been described.6 Extrapleural pneumonectomy (EPP) has been assessed in several studies—most recently in the MARS trial7 as part of trimodality therapy. Lung-sparing approaches, including (extended) pleurectomy with decortication8, 9, 10 and video-assisted thoracoscopic partial pleurectomy (VAT-PP), have also been assessed,11, 12 and might be particularly appropriate for patients with more advanced disease or comorbidities.
VAT-PP involves thoracoscopic debulking of the parietal pleura and visceral pleurectomy with decortication to release trapped lung.6 Results of non-randomised studies examining VAT-PP suggest that VAT-PP improved symptom control compared with EPP11 and possibly increased survival compared with biopsy alone.12 The standard approach to control pleural effusion in patients with malignant pleural mesothelioma is talc pleurodesis, either via a chest tube or, more recently, by thoracoscopy.
The MesoVATS trial was designed to establish whether VAT-PP improves survival in patients with pleural effusion secondary to malignant pleural mesothelioma when compared with talc pleurodesis, to provide a full economic analysis of these treatments, and to compare symptom control and quality-of-life outcomes.
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Study design and participants
MesoVATS was an open-label, parallel-group, multicentre, randomised, controlled trial that recruited patients from 12 secondary or tertiary care hospitals in the UK. Eligible patients were those aged 18 years or older with confirmed (any subtype) or suspected (working diagnosis) malignant pleural mesothelioma who had a pleural effusion. Participants had to be fit enough to undergo VAT-PP and provide informed consent. Exclusion criteria were previous attempted pleurodesis and previous primary
Results
As planned, we recruited 196 patients between Oct 24, 2003, and Jan 24, 2012 (figure 1), and followed them up until Jan 31, 2013, with a further survival update on June 17, 2013. At randomisation, 120 (61%) of 196 patients had confirmed malignant pleural mesothelioma and 76 (39%) had suspected (working diagnosis) malignant pleural mesothelioma (appendix). 11 (11%) of 98 patients assigned to VAT-PP and 10 (10%) of 98 patients assigned to talc pleurodesis with suspected malignant pleural
Discussion
To our knowledge, our study is the first randomised controlled trial to compare VAT-PP and talc pleurodesis in patients with suspected or confirmed malignant pleural mesothelioma. Our results showed that overall survival was not improved by VAT-PP, and that this approach resulted in more complications, longer hospital stays, and was more expensive than was talc pleurodesis.
A study in a similar population of patients—the Mesothelioma and Radical Surgery (MARS) trial7—compared extrapleural
References (31)
- et al.
Continuing increase in mesothelioma mortality in Britain
Lancet
(1995) - et al.
Recommendations for uniform definitions of surgical techniques for malignant pleural mesothelioma: a consensus report of the International Association for the Study of Lung Cancer International Staging Committee and the International Mesothelioma Interest Group
J Thorac Oncol
(2011) - et al.
Extra-pleural pneumonectomy versus no extra-pleural pneumonectomy for patients with malignant pleural mesothelioma: clinical outcomes of the Mesothelioma and Radical Surgery (MARS) randomised feasibility study
Lancet Oncol
(2011) - et al.
Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma
J Thorac Oncol
(2012) - et al.
Improved survival with VATS pleurectomy-decortication in advanced malignant mesothelioma
Eur J Surg Oncol
(2005) - et al.
Systematic review of pleurectomy in the treatment of malignant pleural mesothelioma
Lung Cancer
(2013) - et al.
The expected burden of mesothelioma mortality in Great Britain from 2002 to 2050
Br J Cancer
(2005) - et al.
The European mesothelioma epidemic
Br J Cancer
(1999) - et al.
Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma
J Clin Oncol
(2003) - et al.
Short-term treatment-related symptoms and quality of life: results from an international randomized phase III study of cisplatin with or without raltitrexed in patients with malignant pleural mesothelioma: an EORTC Lung-Cancer Group and National Cancer Institute, Canada, Intergroup Study
J Clin Oncol
(2006)
Extrapleural pneumonectomy versus pleurectomy/decortication in the surgical management of malignant pleural mesothelioma: results in 663 patients
J Thorac Cardiovasc Surg
A systematic review of lung-sparing extirpative surgery for pleural mesothelioma
J R Soc Med
The role of video assisted thoracoscopic pleurectomy/decortication in the therapeutic management of malignant pleural mesothelioma
Eur J Cardiothorac Surg
Prognostic factors in patients with pleural mesothelioma: the European Organization for Research and Treatment of Cancer experience
J Clin Oncol
A proposed new international TNM staging system for malignant pleural mesothelioma from the International Mesothelioma Interest Group
Chest
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