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Management

Referral Information for the New Patient Visit
Patients not previously seen at the BC Cancer Agency may be referred for consultation and management by contacting the Admitting Department of the appropriate regional cancer center. The availability of relevant operative, pathology and imaging laboratory reports will be requested so that these can be obtained prior to the patient being seen, together with the relevant slides and radiographs for review. 

Best Practice Guidelines
All patients with pain require supportive care with aggressive use of analgesics; narcotic analgesics palliate dyspnea as well as pain. Given the restriction in lung function seen in individuals with pleural mesothelioma, strategies to maintain optimum lung function are recommended. Smoking cessation is to be encouraged. Pneumococcal vaccine, and the influenza vaccine when available for the season, should be administered.

Surgery
Patients with stage I mesothelioma are occasionally considered for extrapleuralpneumonectomy in conjunction with chemotherapy and radical radiotherapy. Although some patients have been reported to achieve long-term survival with aggressive therapy, such cases are highly selected and it is unclear whether overall survival has been significantly altered by the treatment modalities applied. Mortality from extrapleuralpneumonectomy ranges from 6% to 30%. As mesothelioma patients suitable for extrapleuralpneumonectomy are rare, such cases should be referred to a thoracic surgeon with experience in performing such operations. Assessment by a multidisciplinary care team including medical and radiation oncologistsis also necessary.

Standard surgical therapy for stages I-IV mesothelioma includes drainage of effusions, chest tube pleurodesis, or thoracoscopicpleurodesis. Effusion control may be difficult because of the restrictive nature of the tumour, although regular drainage may be facilitated by insertion of an indwelling pleural catheter. Selected patients may be considered for palliative surgical resection and decortication. Such procedures may provide temporary relief from effusions but there is no established surgical role for palliation of pain associated with chest wall invasion. Operative mortality from pleurectomy/decortication is about 2%.

Radiotherapy 
The role of radical radiotherapy is limited by the volume being treated (the entire hemithorax), the surrounding structures (heart, liver), and the requirement for delivery of a high dose.  It may be planned following extrapleuralpneumonectomy.

Palliative treatment of more localized symptomatic areas such as painful areas of the chest wall or involvement of the mediastinum may be feasible.

Chemotherapy
Clinical trials support considering treatment of mesothelioma with chemotherapy.  However, as the rate of disease progression is highly variable, it is reasonable for patients who have few or no symptoms to be managed expectantly. A trial of systemic chemotherapy may be offered to fit patients with symptoms requiring palliation. The probability of benefit is greater in those with epithelioidtumours.

Pemetrexed in combination with a platinum analog is a standard consideration due to the survival benefit seen in a large randomized trial that compared pemetrexed pluscisplatin to cisplatin alone. Alternatives include gemcitabine or raltitrexed in combination with a platinum analog, monotherapy with vinorelbine, or an investigational protocol.

Intracavitary therapy with chemotherapeutic agents (cisplatin, mitomycin or cytarabine), cytokines (interferon), radionuclides, and porphyrin/laser have been reported to induce transient regression of mesothelioma but none of these approaches have demonstrated superiority to supportive care only.

Follow-Up
Mesothelioma patients are generally treated palliatively, and follow-up depends on symptomatology and the treatment modalities used. The BCCA doctor in charge should explicitly clarify the physician in charge of palliative patient follow-up. For patients followed by their referring physicians, the BCCA physicians will act as consultants if requested.

References:

  1. Byrne MJ, Davidson JA, Musk AW, et al. Cisplatin and gemcitabine treatment for malignant mesothelioma: a phase II study. J Clin Oncol 1999; 17: 25-30.

  2. Lee CW, Murray N, Anderson H, Rao SC, Bishop W. Outcomes with first-line platinum-based combination chemotherapy for malignant pleural mesothelioma: a review of practice in British Columbia. Lung Cancer 2009; 64: 308-313.

  3. Steele JP, Shamash J, Evans MT, Gower NH, Tischkowitz MD, Rudd RM. Phase II study of vinorelbine in patients with malignant pleural mesothelioma. J Clin Oncol 2000; 18: 3912-3917.

  4. Tsao AS, Wistuba I, Roth JA, Kindler HL. Malignant pleural mesothelioma. J ClinOncol 2009; 27: 2087-2090.

  5. Vogelzang NJ, Rusthoven JJ, Symanowski J, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol 2003; 21: 2636-2644.

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