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Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, 111 Jungbalsan-ro, Ilsandong-gu, Goyang, Gyeonggi 410-769, Korea
(Email: thoracic{at}ncc.re.kr).
I read with interest the article by Yan and colleagues [1]. Therapy of malignant pleural mesothelioma (MPM) has included chemotherapy, gene therapy, hyperthermia, immunotherapy, photodynamic therapy, radiation therapy, surgery, and supportive care. The effect of these various therapies for MPM on patient outcomes has been difficult to assess. At this moment, no therapy has been adequately shown to have any proven benefit in the treatment of MPM. The combination of complete surgery, being decortication or extrapleural pneumonectomy, in combination with hemithorax radiotherapy seems promising only in selected patients. However, only 1% to 2% of all patients with mesothelioma could benefit from surgery combined with external radiotherapy. Not only has little progress been made in the treatment of this disease, it is also clear that very few systematic attempts have been made to evaluate the effects of treatment strategies. Almost without exception, reports are retrospective, with poorly defined patient groups and large variations in treatment schedules. Most reported studies can (at best) be classified as phase I feasibility studies. There are very few properly structured phase II studies and no phase III studies at all, in which a treatment schedule has been randomly compared with no treatment. Also, the staging of MPM remains difficult by any standard. The International Mesothelioma Interest Group (IMIG) has published a modified TNM system that is used to predict prognosis [2]. Rusch and Venkatraman [3] reported a median survival after surgery with adjuvant therapy of 29.9 months for stage I, 19 months for stage II, 10.4 months for stage III, and 8 months for stage IV. The rarity and diversity of MPM can be resolved by the international collaboration with prospective data collection to improve and revise the staging system. Also, the data should be filled up and converted with standardized forms in detail. During the data analysis, the stratification with tumor staging and treatment modalities should be considered.
The prognosis is worse in male patients and in patients with extensive disease, poor performance status, elevated white cell counts, anemia, thrombocytosis, sarcomatoid histologic findings, or high standardized uptake value ratios on positron emission tomography. Expression of certain biochemical markers (cyclo-oxygenase-2 and vascular endothelial growth factor), as well as hypermethylation of the P16 INK4a gene, increased vascularity, and evidence of SV40 virus in the tumor, also indicate a worse prognosis [4]. Adequate patient selection is crucial. The multidisciplinary approach of patients with MPM is emphasized. All newly diagnosed and referred patients with MPM should be discussed by a team of surgeons, thoracic oncologists, radiotherapists, radiologists, pathologists, and nuclear medicine physicians. Similarly, managements of postoperative complications and tumor recurrences need multidisciplinary approaches.
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