Guideline

National comprehensive cancer network (NCCN) v 1.2014 [15]

British thoracic society standards of care committee [16]

European respiratory society/ european society of thoracic surgeons task force[14]

European society of medical oncology guidelines working group[17]

Date Issued/Updated

8/12/2013

8/13/2007

8/28/2009

3/2010

Initial evaluation

CT chest/abdomen Thoracentesis Pleural biopsy Multidisciplinary management PFT, PET, mediastinoscopy for clinical stage I-III and non-sarcomatoid histology.

Multidisciplinary evaluation CT or US-guided tissue biopsy If diagnosis uncertainfollow with interval imaging. Otherwise refer to specialist mesothelioma multidisciplinary team.

Chest CT is suggestive but not diagnostic. (1A) MRI is not relevant for diagnosis (1B). PET scanning is not useful in the initial evaluation (1C).

Thoracoscopy is the best diagnostic tool and should be performed for diagnosis (1A).

Clinical staging is based on CT scan of the chestpleuroscopy or thoracoscopy is required for tissue diagnosis and histologic confirmation.

Supportive Therapy

For inoperable patients, talc pleurodesis or pleural catheter is recommended for management of effusion. Smoking cessation, pain management, anti-emesis and palliative guidelines are referenced.

Early pleurodesis is a key aim for symptom control. Talc is the recommended agent of choice.

Thoracoscopy is a useful diagnostic and thereapeutic tool.

Early pleurodesis should be performed (1C) and sterile talc is preferred (1A). Pain may be managed via general principles but involvement of a pain specialist should be considered (1C).

Local surgical procedures such as partial pleurectomy and pleurodesis are recommended.

Surgical management

Surgical exploration either as primary therapy, or after cisplatin/pemetrexed induction followed by restaging imaging. If resectable, P/D or EPP should be performed by thoracic surgeon with experience in management of MPM. Goal of surgery is complete gross cytoreduction. 3 nodal stations should be sampled.

Radical surgery (EPP) should only be considered in the context of a clinical trial. Surgery should be concentrated in centers of experience. Surgery should be performed in the context of multimodality therapy.

P/D does not offer chance of cure, but should be offered for symptom control (2C). VATS approach is preferred (1C). Radical surgery (EPP) should only be performed in specialized centers, as part of clinical trials, as a component of multimodality therapy.

Surgery should only be performed by experienced centers, and as part of a clinical trial.

Chemotherapy

First-line combination regimens for induction therapy or for palliative control:

Pemetrexed, Cisplatin Pemetrexed, Carboplatin Gemcitabine, Cisplatin Pemetrexed Vinorelbine.

Several agents have shown to be helpful. Clinical trials should be encouraged.

Pemetrexed-cisplatin is recommended as a first-line agent given improved survival versus cicplatin alone.

Every patient should receive best supportive care at a minimum (1A). First-line platinum with pemetrexed or ralitrexed (1B). Alternatively include in first-line clinical trials. Treatment should not be delayed (1C).

Pemetrexed/Cisplatin, and ralitrexed/cisplatin are favored due to available data. Platinum based induction or adjuvant chemotherapy should be used in the setting of surgical management.

Radiation Therapy

Evaluation by radiation oncologist as part of a multidisciplinary team. RT is effective for both local control and symptom control in the palliative setting. It should be considered to prevent instrument-tract recurrence after pleural intervention even in the palliative setting.

Dosimetry should be tailored but as a general rule should include the entire hemithorax, incisions and drain sites. 54Gy as first-line therapy. Doses over 60Gy may be considered for residual tumor.

Radiation plays an important role in the multidisciplinary management. Pain relief has been shown in half of patients, and radiation should also be considered for local complications such as SVC sundrome.

Prophylactic radiotherapy should be used in patients with good performance status after invasive pleural procedures to reduce chest wall implantation.

No definitive recommendation for prophylactic RT due to conflicting data. RT should not be performed after P/D (1A), RT should be performed after EPP in specialized centers, as part of clinical trials, as a component of multimodality therapy (1A).

The role of definitiveRT is unclear; however, radiation has a role in palliation of pain and for prevention of obstructive symptoms. RT may be considered to improve local control after EPP.