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
...Dia...
...inicians should perform an initial th...
...tients for whom antineoplastic treatment is planne...
...hen performing a thoracoscopic biop...
...tients with suspected mesothelioma i...
...ents who are not candidates for thoracosc...
...evaluation of pleural fluid can be...
...c examination should be supplemented...
...lioma should be reported as epithelial, sarcoma...
...cal, thoracoscopic, or open pleural biopsies...
The non-tissue based biomarkers that are u...
...ue based biomarkers that are under evaluati...
...e chest and upper abdomen with IV contr...
...PET/CT should usually be obtained for...
...ies that suggest metastatic disease in the ab...
...(preferably with IV contrast) may b...
...ents being considered for maximal surgical cyt...
...of contralateral pleural abnormalities detected o...
...patients with suspicious findings...
...C/UICC staging classification remains difficult t...
...ptimal approach to mesothelioma measurement re...
...mor volume by CT scan may enhance clinical staging...
...is recommended that tumor response...
Treatment
...Trea...
Chemotherap...
...emotherapy should be offered to patients...
...asymptomatic patients with epithelial histolo...
...ients with a poor performance status (PS...
...mended first-line chemotherapy for patients...
...ddition of bevacizumab to pemetrexed-based c...
...not recommended for patients with PS â‰...
In patients who may not be able to...
...ent with pemetrexed-based chemotherapy may...
...the very limited activity of 2nd line chemotherapy...
...tients for whom clinical trials are n...
...tic patients with epithelial mesotheli...
...line pemetrexed-based chemotherapy should be g...
...here is insufficient evidence to support the us...
Surgical Cy...
...ents with early stage disease, it is s...
...al cytoreduction as a single modality treat...
...ith transdiaphragmatic disease, multifo...
...atients with histologically confirmed...
...atients with ipsilateral histologically-confi...
...eduction (either lung sparing or non-lung sparin...
...ents who have a symptomatic pleural effusion,...
...who have a symptomatic pericardial effusion...
...urgical cytoreduction is not expected to yield an...
...hemotherapy may be given pre- or post-operativ...
...juvant radiation therapy may be associa...
...text of multimodality treatment, fou...
Intracavitary therapies (chemotherapy or photod...
...led pleural catheters are NOT recomm...
...ents who are not candidates for maximal surgical...
...Radiation Thera...
...rophylactic irradiation of intervention t...
...is recommended that adjuvant radiation should...
...py should be offered as an effective treatment mo...
...is recommended that standard dosing regimens use...
...on therapy may be offered to patients with local...
...juvant radiation therapy may be offered to p...
...ithoracic neo-adjuvant radiation therapy...
...mithoracic adjuvant intensity-modulated radiation...
...tential for severe pulmonary toxici...
...alliative radiation therapy, electron...
...uvant or neoadjuvant hemithoracic radiatio...
...mmended that standard dosimetric guideline...