Malignant Pleural Mesothelioma (ERS/ESTS/EACTS/ESTRO, 2020)

Clinical practice guidelines for the management of malignant pleural mesothelioma were released in May 2020 by the European Respiratory Society, European Society of Thoracic Surgeons, European Association for Cardio-Thoracic Surgery, and European Society for Radiotherapy and Oncology.^[1]

Epidemiology Research Priorities

The task force recommends large international epidemiological studies to determine the relationship between pleural plaques and malignant pleural mesothelioma.

Additionally, well-designed clinical trials are needed to determine the effectiveness of CT screening in populations exposed to asbestos.

Further research is needed, and highly encouraged, on biomarkers for malignant pleural mesothelioma, as the ones proposed previously have not proven useful for diagnosis, prognosis, or clinical follow-up for disease monitoring.

Staging Research Priorities

The task force encourages increased prospective data collection regarding tumor thickness and volume measurements.

Additionally, it encourages the prospective use of volumetric assessment software for pretreatment staging investigations.

Other prognostic factors that are important are routine use of the Brims score, in combination with other scores, as part of clinical trials for prospective validation.

Surgery Recommendations & Research Priorities

The task force recommends thorascopic talc poudrage to control recurrent malignant pleural mesothelioma effusions as their first choice to achieve pleurodesis in patients with expanded lungs.

In symptomatic patients who are stable enough to undergo surgery but who will not benefit from chemical pleurodesis or an indwelling catheter, or in whom these have failed, the task force suggests palliative video-assisted thoracic surgery/partial pleurectomy to obtain pleural effusion control.

Malignant pleural mesothelioma patients who are being considered for radical surgery (eg, extrapleural pneumonectomy or pneumonectomy/decortication) should be included in national/international surgical registries or prospective randomized controlled clinical trials.

Radiotherapy Recommendations & Research Priorities

The task force states that palliative radiotherapy should be considered for pain relief at sites of disease caused by local infiltration of normal structures.

Prophylactic drain site radiotherapy is not recommended in routine clinical care.

Postoperative radiotherapy after pleurectomy (with or without decortication) or after extrapleural pneumonectomy should only be considered as part of clinical trials and/or in national/international surgical registries.

Medical Treatment Recommendations & Research Priorities

In patients stable enough for chemotherapy, defined as good performance status, Eastern Cooperative Oncology Group performance status 0-2, and no contraindications, the task force recommends as first-line chemotherapy combination treatment with platinum and pemetrexed, along with folic acid and vitamin B-12 supplementation.

In the event of recurrences, patients who demonstrated extended symptomatic and objective responses with the first-line combination chemotherapy may receive repeat treatment. In all other situations, it is strongly encouraged patients be enrolled in clinical trials.

If bevacizumab is available and patients are stable enough to receive bevacizumab and cisplatin, the task force suggests bevacizumab may be added to cisplatin/pemetrexed chemotherapy as a first-line therapy; however, not in the scenario of macroscopic complete resection.

No definitive recommendations can currently be made for immunotherapy in patients in whom first-line chemotherapy has failed. However, results have been promising and enrollment of these patients in clinical trials is highly recommended.

Multimodal Treatment Research Priorities

In patients considered candidates for a multimodal approach (ie, combinations of surgery, chemotherapy, radiation therapy), the task force recommends these patients receive adequate information on the challenges associated with the multimodal approach. They should be referred to expert centers for inclusion in prospective randomized clinical trials or they should be registered in a large institutional database.

Regarding current and future scores for treatment allocation for malignant pleural mesothelioma, these should always be determined by an expert malignant pleural mesothelioma multidisciplinary board and require prospective validation by multicenter studies.

Follow-Up Care Research Priorities

Assessment of the role of periodic follow-up care with imaging studies, to possibly include chest/abdominal CT scanning, MRI, or positron-emission tomography, should be undertaken in clinical trials.

Signs and symptoms that occur during clinical follow up guide the monitoring of disease progression, and suggested modalities in addition to clinical follow up include chest/abdominal CT scanning every 3-6 months post active treatment for malignant pleural mesothelioma.

For more information, see Mesothelioma.

For more Clinical Practice Guidelines, go to Guidelines.

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