What is the recommended treatment and specialist for pleural Mesothelioma?

Pleural Mesothelioma: Specialist and Treatment Recommendations

For pleural mesothelioma, you need a multidisciplinary team including a medical oncologist, thoracic surgeon, radiation oncologist, and pulmonologist at a specialized center with mesothelioma expertise. 1

Why a Multidisciplinary Team is Essential

Treatment decisions for pleural mesothelioma must be made with multidisciplinary input involving thoracic surgeons, pulmonologists, medical oncologists, and radiation oncologists. 1 This is a strong recommendation based on intermediate-quality evidence because:

• Mesothelioma requires complex staging and treatment planning that no single specialist can optimize alone 1
• Surgical candidacy depends on cardiopulmonary function, disease extent, and ability to receive multimodality therapy 1
• The choice between surgery, chemotherapy, immunotherapy, and radiation varies dramatically based on histologic subtype, stage, and performance status 1

The Medical Oncologist's Role

The medical oncologist is your primary specialist for systemic therapy decisions and overall treatment coordination. 1, 2 They will:

• Determine if you're a candidate for first-line immunotherapy (nivolumab plus ipilimumab) versus chemotherapy based on histologic subtype 1, 2
• For nonepithelioid mesothelioma (biphasic or sarcomatoid): ipilimumab plus nivolumab should be offered as first-line therapy for up to 2 years 1
• For epithelioid mesothelioma: pembrolizumab with pemetrexed plus platinum-based chemotherapy may be offered as first-line therapy 1
• Coordinate timing of systemic therapy with surgical and radiation oncology if multimodality treatment is planned 1

Finding the Right Center

Seek care at a center of excellence with specific mesothelioma experience. 1 This matters because:

• Complex radiation techniques after surgery require specialized expertise to avoid fatal complications 1
• Surgical cytoreduction should only be performed by experienced thoracic surgeons 1
• Multimodality therapy coordination is complex and outcomes are better at high-volume centers 1

Key Treatment Principles by Disease Stage

Early-Stage Disease (Clinical Stage I-III, Good Performance Status)

Maximal surgical cytoreduction should only be considered in highly selected patients who meet strict criteria: 1

• Specific preoperative cardiopulmonary functional criteria are met 1
• No evidence of extrathoracic disease 1
• Able to receive multimodality treatment (adjuvant or neoadjuvant chemotherapy and/or radiation) 1

Surgery alone is insufficient—multimodality therapy with chemotherapy and/or radiation therapy must be administered. 1

Contraindications to maximal surgical cytoreduction: 1

• Histologically confirmed sarcomatoid mesothelioma 1
• Contralateral (N3) or supraclavicular (N3) lymph node involvement 1
• Performance status ≥2 1

Advanced or Unresectable Disease

For patients not candidates for surgery, systemic therapy is the primary treatment: 1, 2

First-line options based on histology: 1

• Nonepithelioid (biphasic/sarcomatoid): Nivolumab plus ipilimumab is FDA-approved and should be offered 1, 2
• Epithelioid: Either pembrolizumab with pemetrexed/platinum chemotherapy OR nivolumab plus ipilimumab may be offered 1

For symptomatic pleural effusions: 1

• Tunneled pleural catheter placement or thoracoscopic pleurodesis should be offered 1
• Talc pleurodesis via thoracoscopy is recommended if no intracavitary therapy is planned 3

Critical Diagnostic Requirements

Before any treatment decision, ensure proper diagnosis: 1

Thoracoscopic biopsy is strongly recommended to: 1

• Enhance clinical staging information 1
• Confirm histologic diagnosis 1
• Accurately determine pathologic subtype (epithelioid, sarcomatoid, biphasic)—this is critical because it determines treatment 1
• Obtain material for molecular profiling 1

Staging workup for surgical candidates: 1

• CT chest and upper abdomen with IV contrast 1
• FDG PET/CT for initial staging 1
• Mediastinoscopy or endobronchial ultrasound if enlarged/PET-avid mediastinal nodes present 1
• Laparoscopy if suspicious intra-abdominal findings and no other contraindications to surgery 1

Common Pitfalls to Avoid

Do not accept cytology alone as definitive diagnosis—cytologic examination of pleural fluid is often negative even with mesothelioma present. 1 Tissue biopsy with immunohistochemistry is required. 1, 3

Do not pursue surgery without confirming epithelioid histology—patients with sarcomatoid mesothelioma should not be offered maximal surgical cytoreduction. 1

Do not place tunneled pleural catheters in surgical candidates—this creates risk of tumor implantation into the chest wall. 1

Do not perform PET/CT after pleurodesis—talc causes pleural inflammation leading to false-positive FDG avidity. 1 Obtain PET/CT before any pleural intervention if possible.