Management of Malignant Pleural Mesothelioma Clinical Practice Guidelines (ESMO, 2022)

European Society for Medical Oncology

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

March 01, 2022

Guidelines for the management of malignant pleural mesothelioma (MPM) were published in February 2022 by the European Society for Medical Oncology (ESMO) in Annals of Oncology.[1]

Role of Surgery

Surgery is recommended for obtaining diagnostic samples of tumor tissue and staging, as well as for palliation of pleural effusions when chest tube drainage is unsuccessful.

Talc poudrage via thoracoscopy is preferred to partial pleurectomy via video-assisted thoracoscopic surgery for pleurodesis.

Macroscopic complete resection (MCR) combined with other modalities is recommended in selected patients.

Extended pleural decortication is preferred to extrapleural pneumonectomy.

First-Line Systemic Therapy

Pemetrexed combined with cisplatin (or carboplatin) and vitamin supplementation for up to six cycles is recommended as a first-line option. Bevacizumab combined with platinum-pemetrexed is also recommended as a first-line option.

For unresectable MPM, nivolumab-ipilimumab for up to 2 years is recommended as a first-line option.

For nonprogressive MPM, maintenance gemcitabine is not routinely recommended but may prolong progression-free survival (PFS) and can be considered when PFS benefits outweigh drawbacks. Maintenance pemetrexed is not recommended after first-line platinum-pemetrexed.

Systemic Therapy for Second Line and Beyond

Single-agent pembrolizumab is a second-line option in immunotherapy-naïve patients. Single-agent nivolumab is a second-line option in pretreated immunotherapy-naïve patients. Nivolumab-ipilimumab can be considered as a second- or third-line option in immunotherapy-naïve patients.

Reintroduction of platinum-pemetrexed or pemetrexed has second-line activity in selected circumstances. Single-agent gemcitabine or vinorelbine has limited second-line activity; gemcitabine-ramucirumab has encouraging activity.

Evidence does not support routine third-line therapy.

Personalized Therapy

PD-L1 expression, immune microenvironment analyses, and tumor mutational burden should not be used to select patients for treatment with immune checkpoint inhibitors.

Routine molecular testing of MPM is not warranted.

In the absence of family history suspicious for a BAP1 syndrome, screening of BAP1-deficient MPM patients for germline mutation is not recommended.

Role of Radiation Therapy

Radiation therapy (RT) can be considered for palliation of pain related to local thoracic infiltration.

Prophylactic RT to prevent chest-wall metastases after pleural procedures is not recommended.

Adjuvant RT can be considered for reducing local failure after MCR; however, evidence does not support it as a standard treatment.

When postoperative RT is applied, strict dose constraints must be adhered to in order to avoid toxicity to organs at risk.

For more information, please go to Mesothelioma and Malignant Pleural Mesothelioma Treatment Protocols.


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