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Malignant pleural mesothelioma

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 Oncology (ASCO 2018).
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Guidelines

1.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.
I
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  • Diagnosis

2.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.
A
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  • Prognosis

3.Diagnostic investigations

Occupational history: as per ESMO 2022 guidelines, elicit occupational history with emphasis on asbestos exposure in patients with suspected MPM.
B

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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

4.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.
B
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  • Thoracentesis

  • Biopsy

  • Contralateral thoracoscopy

  • Laparoscopy

5.Medical management

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

  • First-line systemic therapy

  • Second-line systemic therapy

6.Therapeutic procedures

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

  • Indwelling pleural catheter

7.Surgical interventions

Macroscopic complete resection: as per ESMO 2022 guidelines, perform 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.
B

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  • Extended pleural decortication

  • Palliation of pleural effusion

8.Patient education

General counseling
Provide accurate and understandable information to patients and carers about compensation for MPM.
B
Provide patients with MPM and their carers the opportunity to discuss concerns regarding their disease.
B

9.Follow-up and surveillance

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