Treatment of Malignant Pleural Mesothelioma: General Considerations
There is no standard treatment for mesothelioma, and treatment decisions should be based on prognostic factors including disease stage, histological type, and patient performance status rather than a one-size-fits-all approach. 1
Diagnosis and Staging
Diagnosis requires:
- Thoracoscopy with multiple biopsies (at least 10 samples from multiple sites)
- Immunohistochemical studies for accurate histological typing:
- Epithelioid tumors: cytokeratin (CK 5/6), EMA, calretinin, and negative glandular markers
- Spindle cell tumors: cytokeratin, vimentin, CD34 1
Clinical staging based on:
- CT scan of the chest
- Mediastinoscopy and video-assisted thoracoscopy may be needed
- PET scan to rule out extra-thoracic metastasis 1
Prognostic Factors
Three key favorable prognostic factors:
- Early stage disease (stage I or II)
- Epithelial histology
- Good performance status (0 or 1) 1
Additional factors affecting prognosis:
- Age <70 years is associated with better outcomes
- Receipt of chemotherapy improves survival 1
- Advanced age (85+ years) significantly worsens prognosis 2
Treatment Approaches
Surgery
Surgical options include:
Surgery alone is insufficient and should be combined with additional treatments (chemotherapy and/or radiation) 1
Surgery should only be performed:
- In selected patients with good performance status
- With early stage disease
- By experienced thoracic surgeons
- As part of a multidisciplinary approach 1
Multimodality Treatment
- Systematic reviews show median overall survival of 13-23.9 months with multimodality therapy 1
- Patients receiving surgery with adjuvant therapy have significantly longer survival than those receiving chemotherapy alone (19.8 vs. 11.7 months) 1
- Trimodality therapy (surgery, chemotherapy, radiation) has shown median survival of 32 months in selected patients compared to 10 months with medical treatment alone 4
Chemotherapy
- First-line chemotherapy: cisplatin combined with pemetrexed 5
- Chemotherapy can be administered:
- As primary treatment for non-surgical candidates
- Neoadjuvant (before surgery)
- Adjuvant (after surgery) 1
Radiation Therapy
- Prophylactic irradiation of chest drain tracts and puncture sites is recommended 1
- Intensity-modulated radiation therapy (IMRT) may be used after surgical cytoreduction 1
Early Stage Disease Management
- For stage IA/IB without planned intracavitary treatment, early pleurodesis is recommended 1
- For epithelial-type mesothelioma stage IA/IB with nodules/thickening ≤5mm, intrapleural treatment may be considered 1
Survival Rates
Median survival varies significantly based on treatment approach:
- Medical therapy alone: 11.7 months
- Pleurectomy/decortication: 20.5 months
- Extrapleural pneumonectomy: 18.8 months 1
In patients with favorable prognostic factors (age <70, epithelial histology, receiving chemotherapy):
- Medical therapy: 18.6 months
- P/D: 24.6 months
- EPP: 20.9 months 1
Trimodality therapy can extend median survival to 32 months in carefully selected patients 4
Cost Considerations
While the evidence provided doesn't specifically address cost, mesothelioma treatment is generally expensive due to:
- Need for specialized surgical expertise
- Multimodality treatment approaches
- Extended hospital stays
- Ongoing chemotherapy and radiation treatments
Pitfalls and Caveats
- Avoid radical surgery as a sole treatment - it has not been validated 1
- Surgery should only be performed by experienced thoracic surgeons as part of a multidisciplinary team 1
- Patients with contralateral or supraclavicular lymph node involvement should not undergo maximal surgical cytoreduction 1
- Frozen sections should not be done routinely during diagnostic procedures 1
- The nihilistic approach of waiting for the disease to run its course is unacceptable given the poor prognosis 6