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
...iagnos...
...ns should perform an initial thoracentesis whe...
...or whom antineoplastic treatment is planned...
...hen performing a thoracoscopic bio...
...ith suspected mesothelioma in whom treatment is...
...ents who are not candidates for thoracoscopic b...
...evaluation of pleural fluid can be an initi...
...logic examination should be supplement...
...ould be reported as epithelial, sarcomatoid o...
...racoscopic, or open pleural biopsies with...
...he non-tissue based biomarkers that are under e...
...enomic sequencing is currently done on a...
Staging
A CT scan of the chest and upper a...
...ET/CT should usually be obtained for initial...
...ties that suggest metastatic disease...
...MRI (preferably with IV contrast) may b...
...ng considered for maximal surgical c...
In the presence of contralateral pleu...
...ents with suspicious findings for intra-abdo...
...C/UICC staging classification remains difficult...
...approach to mesothelioma measurement requ...
...of tumor volume by CT scan may enhance clinical...
...ed that tumor response classification...
Treatment
Treatm...
...hemotherapy
...motherapy should be offered to patients with mes...
...n asymptomatic patients with epithelial histology...
...s with a poor performance status (PS 2) may be...
...first-line chemotherapy for patients with...
...n of bevacizumab to pemetrexed-based chemot...
Bevacizumab is not recommended for p...
...may not be able to tolerate cisplatin, carbop...
...atment with pemetrexed-based chemotherapy may be o...
...he very limited activity of 2nd line...
...patients for whom clinical trials are no...
...omatic patients with epithelial mesothelioma an...
...emetrexed-based chemotherapy should...
...re is insufficient evidence to support...
...ical Cytoreduction...
...ients with early stage disease, it is strongly...
...mal surgical cytoreduction as a single mod...
...ransdiaphragmatic disease, multifocal ches...
...nts with histologically confirmed sarcomat...
Patients with ipsilateral histologica...
...mal cytoreduction (either lung sparing or n...
...have a symptomatic pleural effusion, who are PS...
...n patients who have a symptomatic peric...
...nce surgical cytoreduction is not expect...
...y may be given pre- or post-operati...
...vant radiation therapy may be asso...
...he context of multimodality treatment,...
...tracavitary therapies (chemotherapy or phot...
...pleural catheters are NOT recommended i...
...who are not candidates for maximal surgic...
...diation Thera...
Prophylactic irradiation of intervention...
...ommended that adjuvant radiation shou...
...tion therapy should be offered as an eff...
...recommended that standard dosing reg...
...y may be offered to patients with local...
...acic adjuvant radiation therapy may...
...thoracic neo-adjuvant radiation therap...
...cic adjuvant intensity-modulated radiation ther...
...e potential for severe pulmonary toxicity, neoadju...
...palliative radiation therapy, electrons, 2D, 3D,...
...djuvant or neoadjuvant hemithoracic radiation t...
...recommended that standard dosimetric guidelines fo...