Pleural Mesothelioma Medscape

Pleural Mesothelioma Medscape

Malignant Pleural Mesothelioma Treatment Protocols

Treatment Protocols

Treatment protocols for malignant pleural mesothelioma are provided below, including general approaches and treatment by surgical intervention, chemotherapy, radiotherapy, and trimodality therapy.
General treatment approach

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Stage I resectable:

    Patients with operable disease may receive extrapleural pneumonectomy (EPP); if positive margins, add radiation therapy

Stage I unresectable:

    Observation for disease progression or
    Chemotherapy
    Radiation for positive margins

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Stages II-III resectable:

    Induction chemotherapy (cisplatin and pemetrexed) or
    Surgery (pleurectomy/decortication or extrapleural pneumonectomy)
    Radiation
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Stages II-III unresectable:

    Chemotherapy is recommended
    Radiation for palliation and positive margins

Stage IV:

    Chemotherapy
    Radiation post chemotherapy for palliation
    Surgery is not recommended for patients with stage IV disease

Surgical resection
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The 2 surgical procedures commonly used in malignant mesothelioma are pleurectomy with decortication and EPP. For patients with early stage disease with favorable histology and good-risk patients, pleurectomy/decortication (P/D) is a good option. Patients with advanced disease and mixed histology and/or high risk should undergo P/D.
    Pleurectomy with decortication is a more limited procedure and requires less cardiorespiratory reserve; it involves dissection of the parietal pleura, incision of the parietal pleura, and decortication of the visceral pleura, followed by reconstruction; this procedure has a morbidity of 25% and a mortality of 2%
    Extrapleural pneumonectomy is a more extensive procedure than pleurectomy with decortication and has a higher mortality, although in recent years, the mortality has been lowered to 3.8%; this procedure involves dissection of the parietal pleura and division of the pulmonary vessels, as well as en bloc resection of the lung, pleura, pericardium, and diaphragm, followed by reconstruction
    EPP provides the best local control, because it removes the entire pleural sac along with the lung parenchyma
    With surgery alone, the recurrence rate is very high, and most patients die after a few months; at least half of the patients who have local control with surgery have distant metastasis upon autopsy
    In patients with the epithelioid type, if the patient is fit to tolerate a thoracotomy, the best option is still a thoracotomy and macroscopic clearance of the tumor as part of multimodality therapy

Chemotherapy

    Chemotherapy alone is recommended for patients with stage I-IV disease who are not candidates for surgery and for patients with sarcomatoid histology
    The mainstay of treatment is combination chemotherapy with pemetrexed and cisplatin
    Other combination therapies that have also been used are carboplatin and pemetrexed, which is beneficial in patients with poor performance status or who have comorbidities
    Combination cisplatin and gemcitabine may be used if patients cannot take pemetrexed ++

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http://emedicine.medscape.com/article/1999348-overview +

Pleural Mesothelioma Medscape