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Pleural mesothelioma grows in the lining of the lung after asbestos exposure and causes breathlessness and chest pain from fluid and thickening. It is rarely curable; the first-line choice is nivolumab with ipilimumab or pembrolizumab with chemotherapy, and surgery to remove the lining is no longer recommended outside trials.
Pleural mesothelioma is the commonest form of mesothelioma. It presents with pleural effusion, breathlessness and chest wall pain 20 to 50 years after asbestos exposure, and is diagnosed by thoracoscopic biopsy with immunohistochemistry (calretinin, WT1, D2-40) and loss of BAP1 or MTAP. Epithelioid histology, about two thirds of cases, carries a better outlook than biphasic or sarcomatoid disease. CheckMate 743 made nivolumab plus ipilimumab the first new first-line treatment in 16 years, and KEYNOTE-483 added pembrolizumab with platinum-pemetrexed; both are now standard, with histology guiding the choice. MARS 2 showed that extended pleurectomy and decortication harms rather than helps, so surgery is confined to diagnosis, pleurodesis and trials. Hemithoracic radiotherapy, tumour treating fields and mesothelin-directed therapies are the main lines of research.
About four in five mesotheliomas arise in the pleura; roughly 2,500 cases a year in the UK and 3,000 in the US, almost all decades after asbestos exposure, with incidence still rising in countries that banned asbestos late.
Central tumours arise in the large airways, peripheral ones in the alveoli; both drain to hilar then mediastinal nodes, and the pleural lining is a separate cancer site.
Same organ: Mediastinal germ cell tumour, Pleuropulmonary blastoma (types I, Ir, II and III), Type A and type AB thymoma, Type B1 and type B2 thymoma, Type B3 thymoma, Micronodular thymoma with lymphoid stroma, Adenocarcinoma of the lung, Squamous cell carcinoma of the lung, Large cell carcinoma of the lung, Sarcomatoid carcinoma of the lung, Adenosquamous carcinoma of the lung, Invasive mucinous adenocarcinoma of the lung, Adenocarcinoma in situ and minimally invasive adenocarcinoma of the lung, Basaloid squamous cell carcinoma of the lung, Lymphoepithelial carcinoma of the lung, Pulmonary blastoma (adult), Non-small-cell lung cancer, Lung cancer (all types), Small-cell lung cancer, Mesothelioma, Thymoma and thymic carcinoma, Childhood lung and airway tumours (pleuropulmonary blastoma, tracheobronchial tumours), Inflammatory myofibroblastic tumour (IMT), EGFR-mutated non-small-cell lung cancer, ALK-positive non-small-cell lung cancer, KRAS G12C-mutant non-small-cell lung cancer, ROS1-positive non-small-cell lung cancer, MET exon 14 and MET-amplified non-small-cell lung cancer, RET fusion-positive non-small-cell lung cancer, BRAF V600E-mutant non-small-cell lung cancer, HER2-mutant non-small-cell lung cancer, NTRK fusion-positive non-small-cell lung cancer, PD-L1-high non-small-cell lung cancer without a driver mutation, Resectable stage I to III non-small-cell lung cancer, Unresectable stage III non-small-cell lung cancer, Limited-stage small-cell lung cancer, Extensive-stage small-cell lung cancer, Lung neuroendocrine tumours (typical and atypical carcinoid), Large cell neuroendocrine carcinoma of the lung, Thymoma (WHO types A, AB, B1, B2 and B3), Thymic carcinoma
CT and PET-CT; thoracoscopic biopsy with an immunohistochemistry panel; histology and BAP1/MTAP status recorded because they drive treatment.
Nivolumab plus ipilimumab (CheckMate 743).
Pembrolizumab with platinum-pemetrexed (KEYNOTE-483), nivolumab plus ipilimumab, or platinum-pemetrexed with or without bevacizumab, by fitness and preference.
Not recommended for cure outside trials after MARS 2; talc pleurodesis or an indwelling pleural catheter controls effusion.
Nivolumab (CONFIRM) if not given first line; chemotherapy rechallenge or gemcitabine or vinorelbine after immunotherapy.
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Radical surgery for pleural mesothelioma should be confined to trials; effusion is managed with pleurodesis or indwelling catheters and treatment is systemic.
Pembrolizumab with chemotherapy is approved and offered first line, particularly in epithelioid disease where dual immunotherapy showed little benefit over chemotherapy.
Nivolumab-ipilimumab is the preferred first-line treatment for non-epithelioid pleural mesothelioma and an option in epithelioid disease alongside chemo-immunotherapy.
Platinum-pemetrexed remains the chemotherapy backbone in mesothelioma, now combined with pembrolizumab or bevacizumab, or replaced by dual immunotherapy in non-epithelioid disease.
Query for this cancer: (TITLE:"Pleural mesothelioma" OR ABSTRACT:"Pleural mesothelioma" OR TITLE:"Malignant pleural mesothelioma" OR ABSTRACT:"Malignant pleural mesothelioma" OR TITLE:"MPM" OR ABSTRACT:"MPM") AND (treatment OR therapy OR trial OR survival OR diagnosis). Results are unfiltered search hits about Pleural mesothelioma, not a curated reading list.
Thirty-three cases among asbestos miners and their neighbours in South Africa.
The targets of this cancer's medicines and the ones linked to it directly.
Cases by country, the UK and NHS pathway and other country lenses, the expert centres with trials on record, and the centres named on this cancer's subtypes.
One section per setting: the options named, what each is for, the trials behind them, the recorded trade-offs and the questions to ask.
Persistent headache with extreme tiredness, nausea, dizziness on standing or low blood pressure. Vomiting, severe weakness or collapse is adrenal crisis.
Bleeding that does not stop by itself, bleeding from more than one site, or new bruising in several places or one large area.
No pharmacokinetic interactions expected (antibody). See the irAE guide for toxicity management.
Not recommended for CrCl below 45.
Immunotherapy can attack hormone-producing glands: most often the thyroid (usually ending in an under-active thyroid needing lifelong tablets), and less often the pituitary (hypophysitis) or adrenal glands, which can be life-threatening if missed.
Inflammation of the bowel caused by immunotherapy releasing the immune system against the gut lining, producing diarrhoea that can be severe. It is the commonest serious side effect of CTLA-4 antibodies and is treated with steroids and, if needed, infliximab.
See all on the product pages:IpilimumabNivolumabPembrolizumabPemetrexed·Printable cards in the navigator
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