Treatment of Malignant Pleural Mesothelioma
Publication Date: January 18, 2018
Last Updated: December 16, 2022
Diagnosis
Clinicians should perform an initial thoracentesis when patients present with symptomatic pleural effusions and send pleural fluid for cytologic examination for initial assessment for possible mesothelioma. ( EB , I , S )
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Treatment
Chemotherapy
Chemotherapy should be offered to patients with mesothelioma because it improves survival and quality of life. ( EB , I , S )
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In asymptomatic patients with epithelial histology and minimal pleural disease who are not surgical candidates, a trial of close observation may be offered prior to the initiation of chemotherapy. ( IC , , M )
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Selected patients with a poor performance status (PS 2) may be offered single agent chemotherapy or palliative care alone. Patients with a PS of ≥3 should receive palliative care. ( EB , L , M )
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The recommended first-line chemotherapy for patients with mesothelioma is pemetrexed plus platinum. However patients should also be offered the option of enrolling in a clinical trial. ( EB , H , S )
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The addition of bevacizumab to pemetrexed-based chemotherapy improves survival in select patients and therefore may be offered to patients with no contraindications to bevacizumab. The randomized clinical trial demonstrating benefit with bevacizumab utilized cisplatin/pemetrexed. Data with carboplatin/pemetrexed plus bevacizumab is insufficient for a clear recommendation. ( EB , H , M )
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Bevacizumab is not recommended for patients with PS ≥2, substantial cardiovascular comorbidity, uncontrolled hypertension, age >75, bleeding or clotting risk or other contraindications to bevacizumab. ( EB , I , M )
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In patients who may not be able to tolerate cisplatin, carboplatin may be offered as a substitute for cisplatin. ( EB , I , S )
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Re-treatment with pemetrexed-based chemotherapy may be offered in pleural mesothelioma patients who achieved durable (>6 months) disease control with first-line pemetrexed-based chemotherapy. ( EB , L , M )
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Given the very limited activity of 2nd line chemotherapy in patients with mesothelioma, participation in clinical trials is recommended. ( EB , I , S )
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In patients for whom clinical trials are not an option, vinorelbine may be offered as second line therapy. ( EB , L , M )
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In asymptomatic patients with epithelial mesothelioma and a low disease burden who are not surgical candidates, a trial of expectant observation may be offered before initiation of systemic therapy. ( EB , L , M )
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Frontline pemetrexed-based chemotherapy should be given for 4–6 cycles. For patients with stable or responding disease, a break from chemotherapy is recommended at that point. ( EB , L , M )
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There is insufficient evidence to support the use of pemetrexed maintenance in mesothelioma patients and thus it is NOT recommended. ( EB , L , S )
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Overview
Title
Treatment of Malignant Pleural Mesothelioma
Authoring Organization
American Society of Clinical Oncology