➤ Patients with transdiaphragmatic disease, multifocal chest wall invasion
or histologically-confirmed contralateral mediastinal or supraclavicular
lymph node involvement should undergo neoadjuvant treatment before
consideration of maximal surgical cytoreduction. Contralateral (N3) or
supraclavicular disease (N3) disease should be a contraindication to
maximal surgical cytoreduction. (Strong Recommendation; EB-I)
➤ Patients with histologically confirmed sarcomatoid mesothelioma
should NOT be offered maximal surgical cytoreduction. (Strong
Recommendation; EB-I)
➤ Patients with ipsilateral histologically-confirmed mediastinal lymph
node involvement should only undergo maximal surgical cytoreduction
in the context of multimodality therapy (neoadjuvant or adjuvant
chemotherapy). Optimally, these patients should be enrolled in clinical
trials. (Strong Recommendation; EB-I)
➤ Maximal surgical cytoreduction involves either extrapleural
pneumonectomy (EPP) or lung-sparing options (pleurectomy/
decortication (P/D), extended P/D). When offering maximal surgical
cytoreduction, lung-sparing options should be the first choice, due to
decreased operative and long-term risk. EPP may be offered in highly
selected patients when performed in centers of excellence. (Strong
Recommendation; EB-I)
➤ A maximal cytoreduction (either lung sparing or non-lung sparing)
should only be considered in patients who meet specific preoperative
cardiopulmonary functional criteria, have no evidence of extrathoracic
disease, and are able to receive multimodality treatment (adjuvant or
neoadjuvant). (Strong Recommendation; EB-I)
➤ In patients who have a symptomatic pleural effusion, who are PS 2 or
greater, or in whom a maximal cytoreduction cannot be performed (due
to disease extent or co-morbid conditions), palliative approaches such as
a tunneled permanent catheter placement or thoracoscopic exploration
with partial resection and/or pleurodesis should be offered. In the
latter case, additional biopsy to confirm pathological diagnosis should
be performed during the procedure. If the patient is being evaluated
for investigational therapy, material for additional studies (e.g.,
molecular and/or immunological profiling) should be obtained. (Strong
Recommendation; EB-I)
➤ In patients who have a symptomatic pericardial effusion, percutaneous
catheter drainage or pericardial window may be performed. (Strong
Recommendation; EB-H)
