Malignant Pleural Mesothelioma

Last updated May 27, 2022

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

...Diagnosis

...ld perform an initial thoracentesis when patien...


...or whom antineoplastic treatment is planned,...


...rforming a thoracoscopic biopsy, the min...


...with suspected mesothelioma in whom trea...


...are not candidates for thoracoscopic bio...


...ogic evaluation of pleural fluid can be...


...gic examination should be supplemented...


...oma should be reported as epithelial, sarcomato...


...cal, thoracoscopic, or open pleural biopsies with...


...he non-tissue based biomarkers that are u...


...non-tissue based biomarkers that are...


...Staging...

...scan of the chest and upper abdomen with IV contr...

...G PET/CT should usually be obtained for initial st...

...ies that suggest metastatic disease in the a...

...referably with IV contrast) may be obtained...

...ing considered for maximal surgical cytoreduction...

...of contralateral pleural abnormalitie...

...ients with suspicious findings for int...

...urrent AJCC/UICC staging classification remains...

...ptimal approach to mesothelioma me...

...ment of tumor volume by CT scan may enhance...

...s recommended that tumor response classifi...


Treatment

...Chemothera...

...ould be offered to patients with mesothelioma...

...ymptomatic patients with epithelial his...

...d patients with a poor performance status (PS 2...

...d first-line chemotherapy for patients with...

...ition of bevacizumab to pemetrexed-based chemother...

...s not recommended for patients with PS ≥2...

...who may not be able to tolerate cisplat...

...tment with pemetrexed-based chemotherapy may be of...

...limited activity of 2nd line chemotherapy in p...

...whom clinical trials are not an option...

...patients with epithelial mesothelioma and...

...etrexed-based chemotherapy should be gi...

...fficient evidence to support the use of pemetr...


...Surgical...

...ted patients with early stage disease, it is stron...

Maximal surgical cytoreduction as a single mod...

...with transdiaphragmatic disease, multifocal che...

...atients with histologically confirmed sarcomato...

...ients with ipsilateral histologically-confirme...

...with ipsilateral histologically-confirmed med...

...mal cytoreduction (either lung sparing or non...

...s who have a symptomatic pleural effusion, who a...

...ho have a symptomatic pericardial ef...

...ince surgical cytoreduction is not expected to yie...

...motherapy may be given pre- or post-operative...

...djuvant radiation therapy may be as...

...e context of multimodality treatment, four...

...ary therapies (chemotherapy or photodynamic thera...

...unneled pleural catheters are NOT re...

...patients who are not candidates for maximal...


...Radiation T...

...ctic irradiation of intervention t...

It is recommended that adjuvant radiation...

...rapy should be offered as an effective treatme...

...commended that standard dosing regimens...

Radiation therapy may be offered to pati...

...horacic adjuvant radiation therapy may be offe...

...thoracic neo-adjuvant radiation therapy...

...djuvant intensity-modulated radiation...

...the potential for severe pulmonary to...

...lliative radiation therapy, electrons, 2D, 3D,...

...r adjuvant or neoadjuvant hemithoracic...

...ended that standard dosimetric guidelin...