The NCCN Guidelines recommend that patients with MPM be managed by a multidisciplinary team with experience in MPM. Mesothelioma treatment options for patients with MPM include surgery, radiation therapy (RT), and/or chemotherapy; select patients (ie, clinical stages I–III, medically operable, epithelial histology, good performance status [PS]) are candidates for multimodality therapy. Definitive RT alone is not recommended for unresectable MPM; chemotherapy alone is recommended in this setting for patients with PS 0 to 2 (see Treatment in the NCCN Guidelines for Malignant Pleural Mesothelioma).
Mesothelioma treatment(Pretreatment) evaluation for patients diagnosed with MPM is performed to stage patients and to assess whether patients are candidates for surgery. This evaluation includes: 1) chest and abdominal CT with contrast; and 2) FDG-PET/CT but only for patients being considered for surgery. Video-assisted thoracoscopic surgery (VATS) or laparoscopy can be considered if contralateral or peritoneal disease is suspected. PET/CT scans should be obtained before pleurodesis if practical, because talc produces pleural inflammation, which can affect the FDG avidity (ie, false-positive result). However, PET/CT scans are mainly used to assess for metastatic disease. If surgical resection is being considered, mediastinoscopy or endobronchial ultrasonography (EBUS) FNA of the mediastinal lymph nodes is recommended. The following tests may be performed if suggested by imaging: 1) laparoscopy to rule out transdiaphragmatic extension (eg, extension to the peritoneum is indicative of stage IV [unresectable] disease); and 2) chest MRI to evaluate possible chest wall, spinal, diaphragmatic, or vascular involvement.
Surgical staging is performed using the International Mesothelioma Interest Group (IMIG) TNM staging system (see Staging in the NCCN Guidelines for Malignant Pleural Mesothelioma), which was approved by the AJCC. The AJCC cancer staging system was recently updated (8th edition) and became effective on January 1, 2018. Some of the recent changes in the AJCC staging for MPM include: 1) T3 and T4 are now classified as stage IIIB, regardless of N status; 2) former N3 nodes are now classified as N2; 3) former N2 nodes are now classified as N1; and 4) T1a and T1b are now classified as T1. Clinical staging only is done for patients who are not candidates for surgery. It is difficult to clinically stage patients using CT or MRI; therefore, patients who have surgery may be upstaged.
Most patients have advanced disease at presentation. However, it is difficult to accurately stage patients before surgery. Understaging is common with PET/CT. However, PET/CT is useful for determining whether metastatic disease is present. Consideration of surgical resection is recommended for patients with clinical stage I to III MPM (epithelial histology) who are medically operable and can tolerate the surgery. Patients with clinical stage I to III MPM can be evaluated for surgery using pulmonary function tests (PFTs), including diffusing capacity for carbon dioxide (DLCO), perfusion scanning (if forced expiratory volume in 1 second [FEV1] <80%), and cardiac stress tests (see Surgical Evaluation in the NCCN Guidelines for Malignant Pleural Mesothelioma). Multimodality therapy (ie, chemotherapy, surgery, RT) is recommended for patients with clinical stages I to III MPM (epithelial histology) who are medically operable (see Treatment in the NCCN Guidelines for Malignant Pleural Mesothelioma).
Chemotherapy alone is recommended for patients with PS 0 to 2 who are not operable or refuse surgery, those with clinical stage IV MPM, or those with sarcomatoid histology or mixed histology; best supportive care is recommended for patients with PS 3 to 4 (see Chemotherapy in this Discussion and Principles of Chemotherapy and Principles of Supportive Care in the NCCN Guidelines for Malignant Pleural Mesothelioma). Observation for progression may be considered for patients with PS 0 to 2 who are asymptomatic with minimal burden of disease if chemotherapy is planned when progression occurs (either radiologic or symptomatic progression). Pleural effusion can be managed using thoracoscopic talc pleurodesis or placement of a drainage catheter. Therapeutic/palliative thoracentesis can also be used to remove pleural fluid and thus decrease dyspnea either before treatment or for patients who are not candidates for more aggressive treatment.