Guidelines of the European Respiratory Society and the European Society of Thoracic Surgeons for the management of malignant pleural mesothelioma

Our plain-English summary of Guidelines of the European Respiratory Society and the European Society of Thoracic Surgeons for the management of malignant pleural mesothelioma, by A. Scherpereel, P. Astoul, P. Baas, et al (The European Respiratory Journal, 2010).

The study

• Authors: A. Scherpereel, P. Astoul, P. Baas, T. Berghmans, H. Clayson, P. de Vuyst, H. Dienemann, F. Galateau-Salle, C. Hennequin, G. Hillerdal, C. Le Péchoux, L. Mutti, J.C. Pairon, R. Stahel, P. van Houtte, J. van Meerbeeck, D. Waller, W. Weder, European Respiratory Society/European Society of Thoracic Surgeons Task Force
• Journal: The European Respiratory Journal
• Published: 2010;35(3):479-95
• Type of article: Guideline
• Cited by: 430 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Malignant pleural mesothelioma (MPM) is a rare tumour but with increasing incidence and a poor prognosis. In 2008, the European Respiratory Society/European Society of Thoracic Surgeons Task Force brought together experts to propose practical and up-to-dated guidelines on the management of MPM. To obtain an earlier and reliable diagnosis of MPM, the experts recommend performing thoracoscopy, except in cases of pre-operative contraindication or pleural symphysis. The standard staining procedures are insufficient in approximately 10% of cases. Therefore, we propose using specific immunohistochemistry markers on pleural biopsies. In the absence of a uniform, robust and validated staging system, we advice use of the most recent TNM based classification, and propose a three step pre-treatment assessment. Patient's performance status and histological subtype are currently the only prognostic factors of clinical importance in the management of MPM. Other potential parameters should be recorded at baseline and reported in clinical trials. MPM exhibits a high resistance to chemotherapy and only a few patients are candidates for radical surgery. New therapies and strategies have been reviewed. Because of limited data on the best combination treatment, we emphasise that patients who are considered candidates for a multimodal approach should be included in a prospective trial at a specialised centre.

In plain English

This article is a guideline, not an original study. Experts convened by the European Respiratory Society and European Society of Thoracic Surgeons met from May 2007 to November 2008. The experts analysed literature from 1990 to 2009 (from 1965 for chemotherapy) and graded each recommendation. The authors stated that crocidolite, amosite and tremolite have higher pleural carcinogenic potency than chrysotile, that disease may follow low cumulative exposures, and that pleural plaques alone have not clearly been shown to raise risk. They recommended thoracoscopy for diagnosis, except with pre-operative contraindication or pleural symphysis, and immunohistochemistry for every diagnosis. They found no place for screening, but recommended further study in selected highly exposed populations. They recommended assessing asbestos exposure for social security and medico-legal purposes. They restricted radical surgery (extrapleural pneumonectomy) to trials in specialised centres, within multimodal treatment. They advised discussing chemotherapy case by case. If it is given to patients with good performance status, they recommended first-line platinum with pemetrexed or raltitrexed. The authors concluded that data on the best combination treatment are limited and weak, and that candidates belong in prospective randomised trials in specialised centres.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Clinical practice guideline by an expert task force, based on a systematic analysis of the literature (1990 to 2009, and 1965 to 2009 for chemotherapy), with recommendations graded using the American College of Chest Physicians system
• Who was studied: No patient population was studied. Experts on mesothelioma from different scientific societies, convened by the ERS with the ESTS between May 2007 and November 2008, reviewed published literature on malignant pleural mesothelioma.
• Exposure: Asbestos is discussed as the principal cause of malignant pleural mesothelioma (chrysotile, crocidolite, amosite, anthophyllite, tremolite and actinolite). The authors also discuss other agents such as erionite and ionising radiation.
• Main results:
  • The chemotherapy literature search covered 1965 to 2009, wider than the 1990 to 2009 general search
  • In their evidence summary, the authors stated that a dose-response relationship between asbestos and malignant pleural mesothelioma is established, but the disease may occur after low-dose cumulative exposures
  • The authors stated that mesothelioma has been associated with chrysotile exposure, but in most cases the chrysotile was contaminated or associated with amphibole fibres
  • The authors stated there is no clear evidence that pleural plaques alone increase the risk of malignant pleural mesothelioma
  • The guideline recommended that asbestos exposure be evaluated, mainly by occupational and environmental questionnaires, for social security and medico-legal purposes (grade 1A)
  • The guideline stated there is no place for screening for malignant pleural mesothelioma (grade 1B)
  • The guideline recommended further evaluation of thoracic imaging and biological markers in selected highly exposed populations in voluntary surveillance protocols (grade 1B)
  • The guideline recommended thoracoscopy for diagnosis, except in cases of pre-operative contraindication or pleural symphysis (grade 1A)
  • The guideline recommended that the diagnosis always be based on immunohistochemical examination (grade 1A)
  • The guideline named patient performance status and histopathological subtype as the only prognostic factors of current clinical importance (grade 2A)
  • The guideline recommended radical surgery (extrapleural pneumonectomy) only in clinical trials, in specialised centres, as part of multimodal treatment
  • When a decision is made to give chemotherapy, the guideline recommended first-line combination chemotherapy of platinum and pemetrexed or raltitrexed for patients in good performance status (grade 1B)
  • Because evidence of efficacy is limited, the experts advised that the decision to give chemotherapy be discussed with patients and relatives case by case
• The authors' conclusion: The authors concluded that data on the best combination treatment are limited and weak. They recommended that patients considered candidates for a multimodal approach be included in a prospective randomised trial in specialised centres.
• Limitations the authors state:
  • The authors state there is limited evidence for the efficacy of radical surgery
  • Without comparative trials, the authors could give no formal advice on the relative efficacy of the invasive staging investigations
  • The experts could not make a recommendation on prophylactic radiotherapy because its value is questionable
  • The authors cite the grading system's caveat that clinicians must use their own judgment whatever the grade of a recommendation

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Prognosis, Thoracoscopy, Immunohistochemistry, Staging, Performance Status, Histological Subtype, Clinical Trial.

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