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Malignant pleural mesothelioma

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Updated 2023 BTS guidelines for the diagnosis and management of malignant pleural mesothelioma.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of malignant pleural mesothelioma are prepared by our editorial team based on guidelines from the British Thoracic Society (BTS 2023,2018), the European Society of Medical Oncology (ESMO 2022), the Spanish Association of Medical Oncology (SEOM 2021), the European Society for Radiotherapy and Oncology (ESTRO/EACTS/ERS/ESTS 2020), and the American Society of Clinical ...
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Screening and diagnosis

Indications for screening: as per ESMO 2022 guidelines, insufficient evidence to recommend screening for early diagnosis of MPM in patients exposed to asbestos.
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  • Diagnosis

Classification and risk stratification

Staging: as per ESMO 2022 guidelines, use the 8th revision of the UICC TNM staging system for clinical and pathological staging.
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  • Prognosis

Diagnostic investigations

Occupational history: as per ESMO 2022 guidelines, elicit occupational history with emphasis on asbestos exposure in patients with suspected MPM.
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  • Diagnostic imaging (general principles)

  • Diagnostic imaging (X-ray)

  • Diagnostic imaging (ultrasound)

  • Diagnostic imaging (CT)

  • Diagnostic imaging (MRI)

  • Diagnostic imaging (PET/CT)

  • Imaging for staging

  • Molecular testing

  • Biomarkers

Diagnostic procedures

Histopathology: as per ESMO 2022 guidelines, use the current WHO criteria for classifying mesotheliomas, including major subtype and documentation of architectural patterns, grading of epithelioid subtypes and stromal and cytologic features refining prognostication.
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  • Thoracentesis

  • Biopsy

  • Contralateral thoracoscopy

  • Laparoscopy

Medical management

General principles: as per BTS 2023 guidelines, decide on the best treatment modality based on patient choice.
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  • Expectant management

  • First-line systemic therapy

  • Second-line systemic therapy

Therapeutic procedures

Radiotherapy: as per ESMO 2022 guidelines, consider offering radiotherapy for palliation of pain related to local infiltration of thoracic structures.
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  • Pleurodesis

  • Indwelling pleural catheter

Surgical interventions

Macroscopic complete resection: as per ESMO 2022 guidelines, offer macroscopic complete resection in combination with other modalities in selected patients with MPM at experienced centers, discussed with a multidisciplinary team involving thoracic surgeons, pulmonologists, medical and radiation oncologists.
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  • Extended pleural decortication

  • Palliation of pleural effusion

Patient education

General counseling
As per BTS 2018 guidelines:
Provide accurate and understandable information to patients and carers about compensation for MPM.
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Provide patients with MPM and their carers the opportunity to discuss concerns regarding their disease.
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Follow-up and surveillance

Assessment of treatment response: as per ESMO 2022 guidelines, obtain contrast-enhanced CT for the assessment of treatment response.
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