A randomised phase II study of extended pleurectomy/decortication (e-PD) preceded or followed by chemotherapy in patients (pts) with early-stage pleural mesothelioma (PM): EORTC 1205

The European Respiratory Journal 2024 June 26 [Link]

Jo Raskin, Veerle Surmont, Alexander P W M Maat, Maha Yahia, Sjaak A Burgers, Yassin Pretzenbacher, Frederic De Ryck, Robin Cornelissen, Houke M Klomp, Ana Oliveira, Joachim Aerts, Paul Baas, Sandrine Marreaud, Jan P Van Meerbeeck, Paul E Y Van Schil


Background: The role of surgery in pleural mesothelioma remains controversial. It may be appropriate in highly selected patients as part of a multimodality treatment including chemotherapy. Recent years have seen a shift from extrapleural pleuropneumonectomy toward extended pleurectomy/decortication. The most optimal sequence of surgery and chemotherapy remains unknown.

Methods: EORTC-1205-LCG was a multi-centric, non-comparative phase 2 trial, 1:1 randomising between immediate (arm A) and deferred surgery (arm B), followed or preceded by chemotherapy. Eligible patients (ECOG 0-1) had treatment-naïve, borderline resectable T1-3 N0-1 M0 mesothelioma of any histology. Primary outcome was rate of success at 20 weeks, a composite endpoint containing (1) successfully completing both treatments within 20 weeks; (2) being alive with no signs of progressive disease; and (3) no residual grade 3-4 toxicity. Secondary endpoints were toxicity, OS, PFS, and process indicators of surgical quality.

Findings: 69 patients were included in this trial. 56 patients (81%) completed 3 cycles of chemotherapy and 58 patients (84%) underwent surgery. Of the 64 patients in the primary analysis, 21/30 patients in arm A (70.0%; 80% CI: 56.8-81.0) and 17/34 patients (50.0%; 80% CI: 37.8-62.2) in arm B reached the statistical endpoint for rate of success. Median progression-free survival and overall survival were 10.8 [95% CI 8.5-17.2] and 27.1 months [95% CI 22.6-64.3] in arm A, and 8.0 [95% CI 7.2-21.9] and 33.8 months [95% CI 23.8-44.6] in arm B. Macroscopic complete resection was obtained in 82.8% of patients. 30- and 90-day mortality were both 1.7%. No new safety signals were found, but treatment-related morbidity was high.

Interpretation: EORTC 1205 did not succeed in selecting a preferred sequence of pre- or postoperative chemotherapy. Either procedure is feasible with a low mortality, albeit consistent morbidity. A shared informed decision between surgeon and patient remains essential.