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
...agnosi...
...linicians should perform an initial tho...
...for whom antineoplastic treatment is planned,...
...en performing a thoracoscopic biopsy, the mini...
...ith suspected mesothelioma in whom tr...
...atients who are not candidates for t...
...evaluation of pleural fluid can be an ini...
...examination should be supplemented b...
...sothelioma should be reported as epithelial, sarc...
In surgical, thoracoscopic, or open p...
...ased biomarkers that are under evaluation at t...
While tumor genomic sequencing is currently d...
Stagin...
...T scan of the chest and upper abdo...
...should usually be obtained for initial staging o...
...normalities that suggest metastatic...
...referably with IV contrast) may be obtained to fur...
...patients being considered for maximal surgica...
...the presence of contralateral pleural abnormali...
...tients with suspicious findings for intra-ab...
...AJCC/UICC staging classification rem...
...pproach to mesothelioma measurement...
...tumor volume by CT scan may enhance cl...
...ended that tumor response classification be...
Treatment
Treatmen...
...motherapy...
...apy should be offered to patients with mesoth...
...ic patients with epithelial histology an...
Selected patients with a poor perf...
...e recommended first-line chemotherapy...
...ition of bevacizumab to pemetrexed-bas...
...vacizumab is not recommended for patients with P...
...ents who may not be able to tolerate...
...-treatment with pemetrexed-based chemotherapy...
...very limited activity of 2nd line chemotherap...
...whom clinical trials are not an option,...
...matic patients with epithelial mesothelio...
...etrexed-based chemotherapy should b...
...ufficient evidence to support the use of pem...
...rgical Cytoredu...
...ed patients with early stage disease, i...
...surgical cytoreduction as a single mo...
Patients with transdiaphragmatic diseas...
...with histologically confirmed sarcomatoid meso...
...ipsilateral histologically-confirmed...
...reduction (either lung sparing or non-lung sp...
...patients who have a symptomatic pleura...
...nts who have a symptomatic pericardial eff...
...ytoreduction is not expected to yield an R...
...y may be given pre- or post-operative...
...djuvant radiation therapy may be associ...
...he context of multimodality treatment...
...y therapies (chemotherapy or photodynamic the...
...ral catheters are NOT recommended in patients who...
In patients who are not candidates f...
Radiation Therapy
...ctic irradiation of intervention tracts shoul...
...ed that adjuvant radiation should be...
...on therapy should be offered as an effective...
...d that standard dosing regimens used in oth...
...ation therapy may be offered to patients w...
...djuvant radiation therapy may be offered to pa...
...oracic neo-adjuvant radiation therapy may be offer...
...ic adjuvant intensity-modulated radiation t...
...tential for severe pulmonary toxicity, n...
...radiation therapy, electrons, 2D, 3D, and IM...
...or neoadjuvant hemithoracic radiati...
...ecommended that standard dosimetric guidelines...