Mesothelioma: Treatment Modalities and the Multidisciplinary Specialist Team

Malignant mesothelioma (pleural > peritoneal > pericardial/tunica vaginalis) is an aggressive asbestos-related cancer. Treatment requires a specialized multidisciplinary team (MDT).

Treatment by Stage/Resectability

• Resectable (early stage, good PS): Surgery ± multimodal.
  • Pleural: EPP (extrapleural pneumonectomy) vs. extended P/D (pleurectomy/decortication) — MARS 2 trial favors P/D.
  • Peritoneal: CRS (cytoreductive surgery) + HIPEC (hyperthermic intraperitoneal chemotherapy) — standard if CC-0/1 achievable.
• Unresectable / Metastatic: Systemic therapy.
  • First-line: Pemetrexed + platinum (cisplatin/carboplatin) ± bevacizumab (if eligible) — MAPS trial.
  • Second-line: No standard; clinical trials (immunotherapy, ADCs, targeted agents).
  • Immunotherapy: Pembrolizumab/nivolumab (PD-1) show modest single-agent activity; combinations under study.
• Radiation: Palliative (pain, obstruction); adjuvant post-EPP (controversial); definitive for unresectable (rare).

MDT Core Members

Specialist	Role
Medical oncologist	Systemic therapy selection, clinical trial enrollment, symptom management
Thoracic surgeon	EPP, P/D, diagnostic thoracoscopy
Radiation oncologist	Palliative/adjuvant planning, SBRT expertise
Pulmonologist	Pleural effusion management, respiratory optimization, biopsy (EBUS)
Pathologist	Subtyping (epithelioid/sarcomatoid/biphasic), BAP1 IHC, PD-L1, molecular profiling
Radiologist	Staging (CT/PET-MRI), response assessment (mRECIST)
Palliative care	Early integration: dyspnea, pain, advance care planning, psychosocial support
Interventional radiologist	Image-guided biopsy, drainage, fiducial placement

Critical Success Factors

• High-volume center (>20 cases/yr) → better outcomes.
• Molecular profiling (BAP1, CDKN2A, NF2, TMB) guides trials.
• Patient navigation for logistics, financial toxicity, clinical trial access.

Mesothelioma is rare; expertise concentration saves lives.