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
...Diag...
...cians should perform an initial thoracentesis...
...ts for whom antineoplastic treatment is planned...
...a thoracoscopic biopsy, the minimal number o...
...tients with suspected mesothelioma in whom tr...
...tients who are not candidates for...
...evaluation of pleural fluid can be an...
...istologic examination should be supplemente...
...esothelioma should be reported as epithel...
...rgical, thoracoscopic, or open pleu...
...on-tissue based biomarkers that are under evaluati...
...tissue based biomarkers that are unde...
...Staging...
...CT scan of the chest and upper abdomen...
...T should usually be obtained for init...
...that suggest metastatic disease in the abdo...
...MRI (preferably with IV contrast) may be...
...r patients being considered for maximal...
...esence of contralateral pleural abnormaliti...
In patients with suspicious findings...
...t AJCC/UICC staging classification remains...
...roach to mesothelioma measurement requ...
...nt of tumor volume by CT scan may enh...
...recommended that tumor response cl...
Treatment
...Treatment...
...Chemotherap...
...rapy should be offered to patients with m...
...n asymptomatic patients with epithelial histol...
...tients with a poor performance status (...
...recommended first-line chemotherapy for patients...
...e addition of bevacizumab to pemetrexed-based ch...
...umab is not recommended for patients with P...
...ients who may not be able to tolerate cis...
...treatment with pemetrexed-based chemothe...
Given the very limited activity of 2nd line c...
...ts for whom clinical trials are not an...
...matic patients with epithelial mesothelioma and a...
Frontline pemetrexed-based chemotherapy sh...
...insufficient evidence to support the us...
...Surgical Cyt...
...patients with early stage disease, it is stron...
Maximal surgical cytoreduction as a s...
...tients with transdiaphragmatic disease, multifoca...
Patients with histologically confi...
...h ipsilateral histologically-confirmed medi...
...maximal cytoreduction (either lung sparing or n...
...s who have a symptomatic pleural effusion,...
...ents who have a symptomatic pericard...
...ytoreduction is not expected to yield a...
...apy may be given pre- or post-operati...
...vant radiation therapy may be associated with...
...the context of multimodality treatm...
...ry therapies (chemotherapy or photodynamic ther...
...nneled pleural catheters are NOT reco...
...o are not candidates for maximal surgical c...
...Radiation Th...
...tic irradiation of intervention tracts shoul...
...ended that adjuvant radiation should be offered t...
...erapy should be offered as an effective treat...
...nded that standard dosing regimens u...
...n therapy may be offered to patients...
...uvant radiation therapy may be offered to patien...
...racic neo-adjuvant radiation therapy may...
...djuvant intensity-modulated radiation therapy...
...otential for severe pulmonary toxicity...
...tive radiation therapy, electrons, 2D, 3D,...
...adjuvant or neoadjuvant hemithoracic radiat...
...is recommended that standard dosimetr...