ASCO Clinical Practice Guideline: Treatment of Malignant Pleural Mesothelioma

As reported by Hedy L. Kindler, MD, of the University of Chicago, and colleagues in the Journal of Clinical Oncology, ASCO has released a clinical practice guideline on treatment of malignant pleural mesothelioma.

The guideline was informed by a systematic literature search and expert panel review of 222 relevant studies published between 1990 and 2017. The panel was co-chaired by Dr. Kindler and Raffit Hassan, MD, of the National Cancer Institute.

The guideline provides detailed evidence-based recommendations on diagnosis, staging, and treatment of malignant pleural mesothelioma. Select recommendations on chemotherapy, cytoreductive surgery, and radiation therapy are reproduced/summarized below.

Chemotherapy

  • Chemotherapy should be offered to patients with mesothelioma because it improves survival and quality of life.
  • In asymptomatic patients with epithelial histology and minimal pleural disease who are not surgical candidates, a trial of close observation may be offered prior to the initiation of chemotherapy.
  • Selected patients with a poor performance status (PS 2) may be offered single-agent chemotherapy or palliative care alone. Patients with a PS of 3 or greater should receive palliative care.
  • The recommended first-line chemotherapy for patients with mesothelioma is pemetrexed (Alimta) plus platinum. However, patients should also be offered the option of enrolling in a clinical trial.
  • The addition of bevacizumab (Avastin) to pemetrexed-based chemotherapy improves survival in select patients and therefore may be offered to patients with no contraindications to bevacizumab.

Surgical Cytoreduction

  • In selected patients with early-stage disease, it is strongly recommended that a maximal surgical cytoreduction should be performed.
  • Maximal surgical cytoreduction as a single modality treatment is generally insufficient; additional antineoplastic treatment (chemotherapy and/or radiation therapy) should be administered.
  • Patients with transdiaphragmatic disease, multifocal chest wall invasion, or histologically confirmed contralateral mediastinal or supraclavicular lymph node involvement should undergo neoadjuvant treatment before consideration of maximal surgical cytoreduction. Contralateral (N3) or supraclavicular (N3) disease should be a contraindication to maximal surgical cytoreduction.
  • Since surgical cytoreduction is not expected to yield an R0 resection, it is strongly recommended that multimodality therapy with chemotherapy and/or radiation therapy should be administered.
  • Chemotherapy may be given pre- or postoperatively in the context of multimodality treatment.
  • Adjuvant radiation therapy may be associated with a decreased risk of local recurrence and may be offered to patients who have undergone maximal cytoreduction.

Radiation Therapy

  • Prophylactic irradiation of intervention tracts should generally not be offered patients to prevent tract recurrences.
  • It is recommended that adjuvant radiation should be offered to patients who have resection of intervention tracts found to be histologically positive.
  • Radiation therapy should be offered as an effective treatment modality to palliate patients with symptomatic disease.
  • It is recommended that standard dosing regimens used in other diseases be offered to patients with mesothelioma (8 Gy x one fraction, 4 Gy x five fractions, or 3 Gy x 10 fractions).

Additional information is available at https://www.asco.org/practice-guidelines/quality-guidelines/guidelines/thoracic-cancer and www.asco.org/guidelineswiki.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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