Treatment of Malignant Pleural Mesothelioma: American Society of Clinical Oncology Clinical Practice Guideline Summary

Our plain-English summary of Treatment of Malignant Pleural Mesothelioma: American Society of Clinical Oncology Clinical Practice Guideline Summary, by H.L. Kindler, N. Ismaila, R. Hassan (Journal of Oncology Practice, 2018).

The study

• Authors: H.L. Kindler, N. Ismaila, R. Hassan
• Journal: Journal of Oncology Practice
• Published: 2018;14(4):256-264
• Type of article: Guideline
• Cited by: 17 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Summary of the article

This article summarized the American Society of Clinical Oncology (ASCO) clinical practice guideline on managing malignant pleural mesothelioma. The authors described it as an aggressive tumor, with about 3,000 new diagnoses each year in the United States and a median overall survival of approximately 12 months in patients with advanced, surgically unresectable disease. An Expert Panel developed the recommendations from a systematic review of the medical literature, and each recommendation was graded by type, evidence quality and strength.

For diagnosis, the panel recommended thoracentesis with pleural fluid cytology as an initial assessment, thoracoscopic biopsy when treatment was planned, and immunohistochemistry. It also recommended reporting the subtype (epithelial, sarcomatoid or biphasic). Non-tissue-based biomarkers and tumor genomic sequencing were not recommended at that time.

For staging, the panel recommended CT of the chest and upper abdomen with intravenous contrast, usually FDG-PET/CT, and tumor measurement by modified RECIST.

Pemetrexed plus platinum was the recommended first-line chemotherapy. Bevacizumab could be added for selected patients, and pemetrexed maintenance was not recommended.

Maximal surgical cytoreduction was recommended for selected patients with early-stage disease as part of multimodality therapy, with lung-sparing operations as the first choice. It was not to be offered for sarcomatoid histology.

Radiation therapy was recommended for palliation of symptomatic disease. Prophylactic irradiation of intervention tracts was generally not to be offered.

The panel repeatedly advised that patients be offered participation in clinical trials.

PubMed has no abstract for this study, and the article doesn't print one. We wrote this summary from the full article with the help of AI. It is not the authors' wording.

In plain English

This article is a short summary of a clinical practice guideline on malignant pleural mesothelioma from the American Society of Clinical Oncology. It is not a new study. An expert panel wrote the recommendations based on a systematic review of the medical literature. The article does not discuss asbestos or any other cause of the disease. For diagnosis, the panel strongly recommended a thoracoscopic biopsy when treatment is planned. It said that testing pleural fluid alone is not sensitive enough, and that tumors should be reported as epithelial, sarcomatoid or biphasic. The panel recommended pemetrexed plus platinum as first-line chemotherapy, said bevacizumab may be added for some patients, and did not recommend pemetrexed maintenance. For selected patients with early-stage disease, it recommended maximal surgery along with chemotherapy and/or radiation. Lung-sparing operations were the first choice, and maximal surgical cytoreduction was not to be offered for sarcomatoid mesothelioma. Radiation was recommended to relieve symptoms. The authors noted that very few large randomized trials exist because the disease is rare.

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: Summary of a clinical practice guideline; the recommendations were developed by an expert panel based on a systematic review of the medical literature
• Who was studied: Target population: patients with malignant pleural mesothelioma. Intended audience: oncologists, nurses, pulmonologists, radiologists, pathologists, general practitioners and patients
• Exposure: Not addressed. The guideline covers diagnosis, staging and treatment of malignant pleural mesothelioma and does not discuss asbestos or other exposures.
• Main results:
  • When cancer treatment is planned, a thoracoscopic biopsy was strongly recommended (evidence quality high, recommendation strong)
  • Examining pleural fluid cells (cytology) can be an initial screening test but is not sensitive enough to diagnose mesothelioma
  • Mesothelioma should be reported as epithelial, sarcomatoid or biphasic, because these subtypes predict outcome
  • Tumor genomic sequencing was not recommended at this time; it is currently done on a research basis
  • For initial staging, a CT scan of the chest and upper abdomen with intravenous contrast was recommended
  • Chemotherapy should be offered to patients with mesothelioma, according to the guideline because it improves survival and quality of life
  • The recommended first-line chemotherapy was pemetrexed plus platinum (evidence quality high, recommendation strong)
  • Bevacizumab added to pemetrexed-based chemotherapy may be offered to patients without contraindications to it
  • Pemetrexed maintenance therapy was not recommended because of insufficient evidence
  • In selected patients with early-stage disease, maximal surgical cytoreduction was strongly recommended
  • Surgery alone is generally insufficient; chemotherapy and/or radiation therapy should also be given
  • When maximal surgery is offered, lung-sparing operations should be the first choice
  • Patients with confirmed sarcomatoid mesothelioma should not be offered maximal surgical cytoreduction
  • Radiation therapy should be offered to relieve symptoms
  • Preventive radiation of the tracts left by procedures should generally not be offered
• The authors' conclusion: The authors stated that because only a minority of patients can have surgery when first diagnosed, the mainstay of treatment is systemic chemotherapy
• Limitations the authors state:
  • Because the disease is rare, very few large randomized trials exist, especially for surgery
  • Data on carboplatin/pemetrexed plus bevacizumab were insufficient for a clear recommendation
  • The role of intracavitary therapies (chemotherapy or photodynamic therapy) in improving outcome is indeterminate

Topics

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

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Median Overall Survival, Unresectable, Systematic Review, Thoracentesis, Fluid Cytology, Thoracoscopy, Immunohistochemistry.

Related studies

• Summary of presentations from the 46th Annual Meeting of the American Society of Clinical Oncology (2010) focus on tumor biology and biomarkers related to lung cancer — J. Subramanian, L. Corrales, et al. (2011)
• 2015 American Society of Clinical Oncology annual meeting — S. Cleghorn (2015)
• Diagnostic surgical pathology in lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines — A.M. Schwartz, M.K. Rezaei (2013)
• Malignant pleural mesothelioma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up — P. Baas, D. Fennell, et al. (2015)
• Peritoneal mesothelioma: PSOGI/EURACAN clinical practice guidelines for diagnosis, treatment and follow-up — S. Kusamura, V. Kepenekian, et al. (2021)
• Malignant pleural mesothelioma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up — R.A. Stahel, W. Weder, et al. (2010)

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