➤ The current AJCC/UICC staging classification remains difficult to apply
to clinical staging with respect to both T and N components and thus may
be imprecise in predicting prognosis. Physicians should recognize that in
patients with clinical stage I/II disease, upstaging may occur at surgery.
(Strong Recommendation; EB-H)
➤ The optimal approach to mesothelioma measurement requires the
expertise of a radiologist to identify measurement sites on CT as per
modified RECIST for mesothelioma. This approach requires calculating
the sum of ≤6 measurement sites with ≥1 cm thickness measured
perpendicular to the chest wall or mediastinum with ≤2 sites on each of
3 CT sections separated by ≥1 cm axially. (Strong Recommendation; EB-I)
➤ Assessment of tumor volume by CT scan may enhance clinical staging
and provide prognostic information but remains investigational and thus
is NOT recommended. (Strong Recommendation; EB-I)
➤ It is recommended that tumor response classification be determined
based on RECIST criteria from the comparisons of these sums across
serial CT scans. (Strong Recommendation; EB-I)
Chemotherapy
➤ Chemotherapy should be offered to patients with mesothelioma because it
improves survival and quality of life. (Strong Recommendation; EB-I)
➤ 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. (Moderate
Recommendation; IC)
➤ 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 should receive palliative care. (Moderate Recommendation; EB-L)
➤ The recommended first-line chemotherapy for patients with mesothelioma
is pemetrexed plus platinum. However patients should also be offered the
option of enrolling in a clinical trial. (Strong Recommendation; EB-H)
➤ The addition of bevacizumab to pemetrexed-based chemotherapy improves
survival in select patients and therefore may be offered to patients
with no contraindications to bevacizumab. The randomized clinical trial
demonstrating benefit with bevacizumab utilized cisplatin/pemetrexed.
Data with carboplatin/pemetrexed plus bevacizumab is insufficient for a
clear recommendation. (Moderate Recommendation; EB-H)
Treatment
