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
...iagnosis...
...ns should perform an initial thoracentesis when...
...patients for whom antineoplastic treatment is...
...erforming a thoracoscopic biopsy, the minimal num...
...th suspected mesothelioma in whom treatm...
...tients who are not candidates for thoraco...
...logic evaluation of pleural fluid can...
...ologic examination should be supplemented by...
...lioma should be reported as epithelial, sarcomatoi...
In surgical, thoracoscopic, or open pleu...
...non-tissue based biomarkers that are...
...r genomic sequencing is currently done on a rese...
...tagin...
...CT scan of the chest and upper abdomen with IV co...
...should usually be obtained for ini...
...abnormalities that suggest metastatic disease in...
...(preferably with IV contrast) may be obtain...
...r patients being considered for ma...
...sence of contralateral pleural abnormaliti...
In patients with suspicious findings f...
...ent AJCC/UICC staging classification...
...oach to mesothelioma measurement requires...
...essment of tumor volume by CT scan may enhance cli...
...is recommended that tumor response classificati...
Treatment
Treatm...
...hemotherapy...
...herapy should be offered to patients with meso...
...patients with epithelial histology and mini...
...lected patients with a poor perfor...
...recommended first-line chemotherapy...
...bevacizumab to pemetrexed-based chemo...
...acizumab is not recommended for patients with PS â...
...s who may not be able to tolerate cisplatin...
Re-treatment with pemetrexed-based...
...n the very limited activity of 2nd line chemot...
...s for whom clinical trials are not an option, v...
...tic patients with epithelial mesothelioma...
...exed-based chemotherapy should be given for 4â€...
...nsufficient evidence to support the u...
...gical Cytoreductio...
...selected patients with early stage disease, it...
...l surgical cytoreduction as a sing...
...nts with transdiaphragmatic disease, mul...
...ts with histologically confirmed sarcom...
...atients with ipsilateral histologically-confirmed...
...toreduction (either lung sparing or non-lung...
...patients who have a symptomatic pleur...
...patients who have a symptomatic pericardial ef...
...e surgical cytoreduction is not expecte...
...therapy may be given pre- or post-o...
...on therapy may be associated with a decreased ris...
...xt of multimodality treatment, four...
...racavitary therapies (chemotherapy or pho...
...eled pleural catheters are NOT rec...
...ients who are not candidates for maximal sur...
...adiation Ther...
...adiation of intervention tracts should generally...
...d that adjuvant radiation should be o...
...y should be offered as an effective treatme...
...ommended that standard dosing regimens use...
...adiation therapy may be offered to patients w...
...thoracic adjuvant radiation therapy may be offer...
...horacic neo-adjuvant radiation therapy ma...
...horacic adjuvant intensity-modulated...
...the potential for severe pulmonary...
...tive radiation therapy, electrons, 2D, 3D, and IM...
...ant or neoadjuvant hemithoracic radiation t...
...ecommended that standard dosimetric gui...