Malignant Pleural Mesothelioma
Key Points
Key Points
- Mesothelioma should be reported as epithelial, sarcomatoid or biphasic, because these subtypes have a clear prognostic significance.
- The optimal approach to mesothelioma measurement requires the expertise of a radiologist to identify measurement sites on CT as per modified RECIST for mesothelioma.
- When offering maximal surgical cytoreduction, lung-sparing options (pleurectomy/decortication (P/D), extended P/D) should be the first choice, due to decreased operative and long-term risk. Extrapleural pneumonectomy (EPP) may be offered in highly selected patients when performed in centers of excellence.
- Maximal surgical cytoreduction as a single modality treatment is generally insufficient; additional anti-neoplastic treatment (chemotherapy and/or radiation therapy) should be administered. It is recommended that this treatment decision should be made with multidisciplinary input.
- Chemotherapy should be offered to patients with mesothelioma because it improves survival and quality of life.
- The recommended first-line chemotherapy for patients with mesothelioma is pemetrexed plus platinum. Patients should also be offered the option of enrolling in a clinical trial.
- 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.
- In patients who may not be able to tolerate cisplatin, carboplatin may be offered as a substitute for cisplatin.
- Radiation therapy should be offered as an effective treatment modality to palliate patients with symptomatic disease.
Diagnosis
...agnosis...
Clinicians should perform an initial thoracente...
...nts for whom antineoplastic treatment is planned,...
...en performing a thoracoscopic biopsy, the m...
...tients with suspected mesothelioma in wh...
...o are not candidates for thoracoscopic...
...logic evaluation of pleural fluid can...
Histologic examination should be supplement...
...esothelioma should be reported as epithelia...
...al, thoracoscopic, or open pleural biopsies w...
...based biomarkers that are under evaluation a...
...umor genomic sequencing is currently done on...
...taging...
...he chest and upper abdomen with IV contra...
...FDG PET/CT should usually be obtained for initial...
...malities that suggest metastatic disease...
...RI (preferably with IV contrast) may be...
...being considered for maximal surgical cytoredu...
...of contralateral pleural abnormalities detected...
...with suspicious findings for intra...
...t AJCC/UICC staging classification remai...
The optimal approach to mesotheliom...
...umor volume by CT scan may enhance clinical stagin...
...nded that tumor response classification be determi...
Treatment
...reatmen...
...emotherap...
...emotherapy should be offered to patients...
...tomatic patients with epithelial histology and min...
...patients with a poor performance status (PS 2...
...recommended first-line chemotherapy for...
...tion of bevacizumab to pemetrexed-b...
...zumab is not recommended for patien...
...tients who may not be able to tolerate cisplati...
...with pemetrexed-based chemotherapy may be off...
...limited activity of 2nd line chemo...
...ents for whom clinical trials are not an opti...
...tic patients with epithelial mesoth...
...pemetrexed-based chemotherapy should b...
There is insufficient evidence to suppor...
...gical Cytoreduction
...patients with early stage disease, it is stro...
...surgical cytoreduction as a single mod...
...s with transdiaphragmatic disease, m...
Patients with histologically confirmed s...
...silateral histologically-confirmed mediastina...
...eduction (either lung sparing or non-lung s...
...who have a symptomatic pleural eff...
...patients who have a symptomatic pericardial eff...
...rgical cytoreduction is not expected to y...
...erapy may be given pre- or post-operatively in the...
...nt radiation therapy may be associat...
...ntext of multimodality treatment, four to six cycl...
...vitary therapies (chemotherapy or photodynami...
...d pleural catheters are NOT recommended...
...tients who are not candidates for maximal s...
...iation Therapy...
...ctic irradiation of intervention tract...
...commended that adjuvant radiation s...
...erapy should be offered as an effe...
...ed that standard dosing regimens used in o...
...n therapy may be offered to patients wi...
...adjuvant radiation therapy may be offered to pati...
...emithoracic neo-adjuvant radiation therapy may be...
...adjuvant intensity-modulated radiation therapy...
...tial for severe pulmonary toxicity, neo...
...adiation therapy, electrons, 2D, 3D, an...
...adjuvant or neoadjuvant hemithoracic radiation the...
...commended that standard dosimetric g...