• Arian Mansur, Alexandra L Potter, Alexander J Zurovec, Krithika V Nathamuni, R Ryan Meyerhoff, Mark F Berry, Augustine Kang, and Jeffrey YangChi-FuCFMassachusetts General Hospital, Boston, MA. Electronic address: cjyang@mgh.harvard.edu..
• Harvard Medical School, Boston, MA.
• Chest. 2023 May 1; 163 (5): 129213031292-1303.

BackgroundThe role of cancer-directed surgery in the treatment of stage I-IIIA malignant pleural mesothelioma (MPM) by histologic subtypes remains controversial. The objective of this study was to evaluate the survival of the different histologic subtypes for stage I-IIIA MPM stratified by cancer-directed surgery and nonoperative management.Research QuestionHow is the histologic subtype, clinical stage, and use of cancer-directed surgery for MPM associated with overall survival?Study Design And MethodsOverall survival of patients with stage I-IIIA epithelioid, sarcomatoid, and biphasic MPM in the National Cancer Database from 2004 through 2017 who underwent cancer-directed surgery (ie, surgery with or without chemotherapy or radiation) or chemotherapy with or without radiation (nonoperative management) was evaluated using Kaplan-Meier analysis, multivariable Cox proportional hazards analysis, and propensity score-matched analysis.ResultsOf 2,285 patients with stage I-IIIA MPM who met inclusion criteria, histologic subtype was epithelioid in 71% of patients, sarcomatoid in 12% of patients, and biphasic in 17% of patients. Median survival was 20 months in the epithelioid group, 8 months in the sarcomatoid group, and 13 months in the biphasic group (P < .01). Among patients who underwent surgery, median survival was 25 months in the epithelioid group, 8 months in the sarcomatoid group, and 15 months in the biphasic group (P < .01). In multivariable Cox proportional hazards analyses, surgery was associated with improved survival in the epithelioid group (P < .01) but not in the sarcomatoid (P = .63) or biphasic (P = .21) groups. These findings were consistent in propensity score-matched analyses for each MPM histologic type.InterpretationIn this national analysis, cancer-directed surgery was found to be associated with improved survival for stage I-IIIA epithelioid MPM, but not for biphasic or sarcomatoid MPM.Copyright © 2022 American College of Chest Physicians. All rights reserved.

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