Treatment Option Overview for Malignant Mesothelioma

Standard treatment for all but localized mesothelioma is generally not curative. Some patients will experience long-term survival with aggressive treatment approaches, but it remains unclear if overall survival (OS) is significantly altered by different treatment modalities or combinations of modalities.

Extrapleural pneumonectomy may improve the recurrence-free survival of selected patients with early-stage disease, but the impact on OS is unknown.[1] Pleurectomy and decortication can provide palliative relief from symptomatic effusions, discomfort caused by tumor burden, and pain caused by invasive tumor. For more information, see Cancer Pain. Trimodality therapy refers to a combination of chemotherapy, definitive surgery, and radiation therapy. Because of the rarity of mesothelioma and the complexities of patient selection, surgical technique, and optimal sequencing of therapy, delivery of such therapy in centers with established experience and expertise in the management of mesothelioma has shown better results. Operative mortality from pleurectomy with decortication is less than 2%,[2] while mortality from extrapleural pneumonectomy ranges from 6% to 30%.[1,3]

Several single-arm phase II studies have demonstrated prolonged survival times (compared with historical controls) for selected patients who received adjuvant radiation therapy after definitive surgery.[2,4,5] Most patients with pleural mesothelioma who receive radiation therapy experience pain relief, but symptom control is short-lived.[6,7] Other single-arm phase II studies investigated neoadjuvant chemotherapy (mainly with platinum and pemetrexed or gemcitabine) followed by definitive surgery and adjuvant radiation therapy.[8-10] These studies have also shown prolonged survival compared with historical controls; however, this advantage has yet to be confirmed in a randomized study.