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
...agnosis...
...uld perform an initial thoracentesis when patien...
...ients for whom antineoplastic treatment is...
...a thoracoscopic biopsy, the minimal number of inci...
...with suspected mesothelioma in whom treatment i...
...ho are not candidates for thoracos...
...tion of pleural fluid can be an initial s...
...logic examination should be supple...
...should be reported as epithelial, sa...
...racoscopic, or open pleural biopsies with suff...
...on-tissue based biomarkers that are under evaluat...
...genomic sequencing is currently done on a rese...
...taging
...of the chest and upper abdomen with IV contrast...
...FDG PET/CT should usually be obtained...
...bnormalities that suggest metastatic disease in t...
...MRI (preferably with IV contrast) may be ob...
...ng considered for maximal surgical cytored...
...presence of contralateral pleural a...
In patients with suspicious findings for intra-a...
...current AJCC/UICC staging classification...
...imal approach to mesothelioma measurement...
...of tumor volume by CT scan may enha...
...recommended that tumor response classification...
Treatment
...eatmen...
...otherapy...
...uld be offered to patients with mes...
...tic patients with epithelial histology and m...
...ts with a poor performance status (PS 2) may be of...
...ded first-line chemotherapy for patients...
...on of bevacizumab to pemetrexed-based...
...ab is not recommended for patients with PS...
...patients who may not be able to tolerate ci...
...th pemetrexed-based chemotherapy may b...
...he very limited activity of 2nd line chemother...
In patients for whom clinical trials are n...
...patients with epithelial mesothelioma...
Frontline pemetrexed-based chemother...
...is insufficient evidence to support the use...
...rgical Cytoreduction
...ted patients with early stage disease,...
Maximal surgical cytoreduction as a single mo...
...ents with transdiaphragmatic disease, mu...
...tients with histologically confirmed sarcomatoid...
...ients with ipsilateral histologicall...
...duction (either lung sparing or non-lung...
...ients who have a symptomatic pleural effusi...
In patients who have a symptomatic p...
...cytoreduction is not expected to yield an R0 rese...
...rapy may be given pre- or post-operatively i...
...radiation therapy may be associat...
...f multimodality treatment, four to six cyc...
...vitary therapies (chemotherapy or photody...
...al catheters are NOT recommended in patients wh...
...who are not candidates for maximal surgi...
Radiation Thera...
...rophylactic irradiation of intervention tracts sh...
...nded that adjuvant radiation should...
...diation therapy should be offered as an...
...mmended that standard dosing regimens use...
Radiation therapy may be offered to pati...
Hemithoracic adjuvant radiation therapy may be o...
...c neo-adjuvant radiation therapy may be...
...ic adjuvant intensity-modulated ra...
...o the potential for severe pulmonary toxicity,...
...radiation therapy, electrons, 2D, 3D, and I...
...r adjuvant or neoadjuvant hemithora...
...recommended that standard dosimetric guid...