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
Diagno...
...ld perform an initial thoracentesis w...
...or whom antineoplastic treatment is p...
...ng a thoracoscopic biopsy, the minimal number...
...ents with suspected mesothelioma in w...
...o are not candidates for thoracosco...
...ogic evaluation of pleural fluid can be an initi...
...c examination should be supplement...
...ma should be reported as epithelial,...
...urgical, thoracoscopic, or open pleura...
...non-tissue based biomarkers that are under eva...
...hile tumor genomic sequencing is current...
...tagin...
...of the chest and upper abdomen with IV contra...
...CT should usually be obtained for i...
...s that suggest metastatic disease in the abdomen a...
An MRI (preferably with IV contrast) may be obtain...
...ents being considered for maximal surgical cytored...
...e presence of contralateral pleural abno...
In patients with suspicious findings for in...
...e current AJCC/UICC staging classifica...
...he optimal approach to mesothelioma me...
...f tumor volume by CT scan may enhance clini...
...ended that tumor response classification be det...
Treatment
...reatment
...otherapy...
...uld be offered to patients with mesothelio...
In asymptomatic patients with epithelial histology...
...ected patients with a poor performance stat...
...ded first-line chemotherapy for pat...
The addition of bevacizumab to pemetre...
...s not recommended for patients with...
...ho may not be able to tolerate cisplatin,...
...atment with pemetrexed-based chemother...
...the very limited activity of 2nd line...
In patients for whom clinical trials a...
...omatic patients with epithelial mesothelio...
...ntline pemetrexed-based chemotherapy should...
...insufficient evidence to support the use of peme...
Surgical Cytore...
...elected patients with early stage disease, i...
...surgical cytoreduction as a single modalit...
...with transdiaphragmatic disease, multifocal ch...
...tients with histologically confirmed sa...
...ts with ipsilateral histologically-conf...
...mal cytoreduction (either lung spa...
...have a symptomatic pleural effusion, who are...
...ients who have a symptomatic pericardial effusion...
...ince surgical cytoreduction is not...
...otherapy may be given pre- or post-ope...
...vant radiation therapy may be associate...
...e context of multimodality treatmen...
Intracavitary therapies (chemotherapy...
...unneled pleural catheters are NOT recommend...
...who are not candidates for maximal s...
...diation Therapy
...ylactic irradiation of intervention tracts...
...mmended that adjuvant radiation shou...
...n therapy should be offered as an effective trea...
...ommended that standard dosing regimens used in oth...
...y may be offered to patients with localized asym...
...uvant radiation therapy may be offered to...
...-adjuvant radiation therapy may be of...
...adjuvant intensity-modulated radiation thera...
...e potential for severe pulmonary toxicity...
...palliative radiation therapy, electron...
...t or neoadjuvant hemithoracic radiatio...
...recommended that standard dosimetric g...