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Ann Thorac Surg 2006;82:2337
© 2006 The Society of Thoracic Surgeons
Harbor-UCLA
(Email: y.aelony{at}cox.net).
The article by Rice and colleagues [1] is an important study that correctly steers attempts at "curative resection" of malignant mesothelioma to those patients with very limited, locoregional disease by using laparoscopy, cervical mediastinoscopy, and peritoneal lavage to rule out more advanced disease. Their large database helps us understand the tumor burden at the time of presentation of this very aggressive neoplasm. Hopefully the comments that follow and the responses to my questions may further strengthen this important contribution.
Although we hope to cure pleural mesotheliomas in the future, it has not happened yet. The statement that "occasional patients with N2 metastases who are cured with multimodality therapy" seems to be an error; I could not find this statement in the authors Reference 16 [2], and indeed, the authors in that reference wrote 3 years later that the disease "is still invariably fatal" [3].
In the discussion of their article, Rice and colleagues [1] state that "there are patients who do have N2 disease in our series who are long-term survivors." It would be of interest to learn the exact longevity of the authors’ long-term N2 survivors and to compare the data with, for instance, the historical 11% of "untreated patients" reported to live 48 months after the onset of symptoms [4].
Rice and coworkers’ statement, "I believe that N2 positivity is probably not a marker of local recurrence but rather a marker of distant disease" is pertinent in that some reports imply that removing all the N2 nodes may lead to a surgical cure. Although surgical cure has proved to be the case in as much as 29% of selected N2 lung cancer patients, it has never been shown, to my knowledge, in malignant mesothelioma.
Although forced feeding has been ineffective in some malignancies with weight loss in humans, jejunostomy feeding tubes were placed in 8 mesothelioma patients with weight loss. Survival data in this subgroup of patients would be most interesting.
Demonstration of whether newer treatment modalities are worthwhile in this disease will depend on performing phase III trials, as in the currently British Thoracic Society study underway, which randomizes patients to aggressive care and best supportive care groups [5]. We have recently shown that an unselected, consecutive group of mesothelioma patients presenting with pleural effusions may live an average of 24 months (median, 19 months) after diagnosis, with thoracoscopic talc poudrage as the primary treatment modality [6]. Although the absence of surgical staging in our series prevents more direct comparisons with surgical series, our study demonstrates that the assumption of a 6 to 12 survival is not a reliable comparative in current research. Thoracoscopic talc poudrage is an ideal control for phase III studies because of its proven palliation and negligible morbidity [6].
Last, for maximum staging accuracy, noninvasive predictors of survival should be incorporated into future studies, including pleural pH [7, 8], Karnofsky status, intensity of 18 F-fluoro-deoxyglucose in positron-emission tomographic scans [9], and tumor necrosis grading of biopsies [10].
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  D. Rice Reply Ann. Thorac. Surg., December 1, 2006; 82(6): 2337 - 2338. [Full Text] [PDF]
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