Quoted from http://annonc.oxfordjournals.org/content/21/suppl_5/v126.full
Malignant pleural mesothelioma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up
- R. A. Stahel 1,
- W. Weder 2,
- Y. Lievens 3,
- E. Felip 4, and
- On behalf of the ESMO Guidelines Working Group*
+ Author Affiliations
1Clinic and Policlinic of Oncology
2Department of Thoracic Surgery, University Hospital of Zürich, Zürich, Switzerland
3Radiation Oncology Department, Leuven University Hospitals, Leuven, Belgium
4Medical Oncology Service, Vall d’Hebron University Hospital, Barcelona, Spain
*Correspondence to: ESMO Guidelines Working Group, ESMO Head Office, Via L. Taddei 4, CH-6962 Viganello-Lugano, Switzerland; E-mail: clinicalrecommendations@esmo.org
incidence
Malignant pleural mesothelioma (MPM) is a rare tumour. The incidence is 1.25/100 000 in Great Britain and 1.1/100 000 in Germany. Within the next 20 years the incidence is estimated to double in many countries. Exposure to asbestos is a well-established aetiological factor for MPM, with occupational exposure being documented in 70%–80% of those affected.
diagnosis
Patients typically present with shortness of breath due to pleural effusion or chest pain in a more advanced stage. The diagnosis is usually suggested by imaging studies (unilateral pleural thickening; pleural effusion). An occupational history must be obtained.
Cytological examination of the effusion can be diagnostic, but often shows equivocal results. Therefore, histology, including immunohistochemistry, is the gold standard. Pleuroscopy, a video-assisted surgical procedure or open pleural biopsy in a fused pleural space may be necessary to provide sufficient material for accurate histological diagnosis. There are three main histological types (epithelial, sarcomatous and mixed) with ?60% being epithelial.
Data suggest the possible contribution of serum mesothelin-related proteins and osteopontin as useful markers to support the diagnosis of mesothelioma; however, the precise role of these markers is yet to be defined.
staging and risk assessment
Clinical staging is based on the CT scan of the chest. However, the translation of the images into TNM stages is often not conclusive. Mediastinoscopy and video-assisted thoracoscopy may be useful in determining the stage. Accurate initial staging is essential to provide both prognostic information and guidance on the most appropriate therapeutic options. Several different staging systems exist, among them the international IMIG staging system for MPM which emphasizes the extent of disease post-surgery in a traditional TNM system and stratifies patients into prognostic categories similar to those shown in Table 1.
View this table:
Table 1.
TNM staging system for MPM
The European Organization for Research and Treatment of Cancer prognostic scores may be used. They include performance status, gender, certainty of histology, histological type and white blood count.
MPM rarely metastasizes to distant sites but most patients present with locally advanced disease. The use of PET scan to rule out extra-thoracic metastasis in patients considered for radical treatment is under investigation and findings seem promising.
