Advanced Malignant Mesothelioma (Stages II, III, and IV)
Standard treatment options:
- Symptomatic treatment to include drainage of effusions, chest tube pleurodesis, or thoracoscopic pleurodesis. (Refer to the PDQ summary on Cardiopulmonary Syndromes for more information.)
- Palliative surgical resection in selected patients.[2,3]
- Palliative radiation therapy.[4,5]
- Single-agent chemotherapy. Partial responses have been reported with doxorubicin, epirubicin, mitomycin, cyclophosphamide, cisplatin, carboplatin, and ifosfamide.[6-8]
- Combination chemotherapy (under clinical evaluation).[6,7,9] Information about ongoing clinical trials is available from the NCI Web site.
- Multimodality clinical trials.[10-13]
- Intracavitary therapy. Intrapleural or intraperitoneal administration of chemotherapeutic agents (e.g., cisplatin, mitomycin, and cytarabine) has been reported to produce transient reduction in the size of tumor masses and temporary control of effusions in small clinical studies.[14-16] Additional studies are needed to define the role of intracavitary therapy.
A large, randomized study from the United Kingdom (BTS-MRC-MS01) compared active symptom control (ASC) with the chemotherapy regimens of mitomycin C, vinblastine, and cisplatin (MVP) or single-agent vinorelbine. The trial was sized to detect a difference of 9 to 12 months in median survival with a total of 840 patients. As a result of slow accrual, the two chemotherapy regimens were collapsed, and the statistical plan revised. In a total of 409 patients, no significant difference in survival was detected between ASC and chemotherapy.[Level of evidence: 1iiA]
Many phase II trials of chemotherapy have been reported.[6,7,9] The safety and efficacy of pemetrexed, an antifolate, and cisplatin in chemotherapy-naive patients with malignant mesothelioma who were not eligible for curative surgery was demonstrated in a randomized phase III trial.[Level of evidence: 1iiA] This trial compared pemetrexed (500 mg/m2) and cisplatin (75 mg/m2 on day 1) with cisplatin alone (75 mg/m2 on day 1 intravenously every 21 days). With a total of 456 enrolled patients in the trial, 226 patients received pemetrexed plus cisplatin, 222 patients received cisplatin alone, and 8 patients did not receive therapy. After 117 patients had enrolled, folic acid and vitamin B12 were added to reduce toxic effects. Folic acid (350–1,000 µg orally) was given daily, beginning 1 to 3 weeks before the first chemotherapy dose and continuing daily until 1 to 3 weeks after treatment ended. A vitamin B12 injection (1,000 µg intramuscularly) was administered 1 to 3 weeks before the first chemotherapy dose and was repeated approximately every 9 weeks until treatment ended. Dexamethasone (4 mg) or an equivalent corticosteroid was administered orally twice daily for skin rash prophylaxis to all patients 1 day before, on the day of, and 1 day after each pemetrexed dose.
In an analysis of all patients who were randomly assigned and treated, the combination of pemetrexed and cisplatin was associated with a statistically significant improvement in survival compared with cisplatin alone; the median survivals were 12.1 versus 9.3 months, respectively (P = .020). The hazard ratio for death of patients in the pemetrexed plus cisplatin arm versus those in the control arm was 0.77. Median time-to-progression was significantly longer in the pemetrexed plus cisplatin arm (5.7 months vs. 3.9 months, P = .001). This superiority in the combination arm was also demonstrated in the vitamin-supplemented subgroup. The median survivals were 13.3 and 10.0 months in the combination group and cisplatin alone group, respectively (P = .051). The principal adverse effects of the pemetrexed plus cisplatin regimen were myelosuppression, fatigue, nausea, vomiting, and dyspnea. Most grade 3 to 4 adverse effects were significantly reduced by vitamin supplementation without any decrease in efficacy.
A randomized, phase III trial of 250 patients was performed by the European Organisation for Research and Treatment of Cancer (EORTC-08983) to compare cisplatin alone with the combination of raltitrexed, a thymidine synthase inhibitor, and cisplatin in first-line treatment of patients with malignant pleural mesothelioma. Cisplatin (80 mg/m2 IV) was given on day 1, alone or combined with raltitrexed (3 mg/m2). No toxic deaths resulted, and the main grade 3 or 4 toxicities observed were neutropenia and emesis, which were reported twice as often in the combination arm. Among 213 patients with measurable disease, the response rate was 13.6% versus 23.6%, respectively (P = .056). No difference in quality of life was observed. The combination arm was associated with an increased survival. Median overall and 1-year survival were 8.8 versus 11.4 months, respectively and 40% versus 46%, respectively (P = .048).[Level of evidence: 1iiA]Malignant Peritoneal Mesothelioma
A multi-institutional, registry study evaluated cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for diffuse, malignant peritoneal mesothelioma. Among 401 patients, 187 (46%) had complete or near-complete cytoreduction, and 372 (92%) received HIPEC. Of the HIPEC patients, 311 (83%) received cisplatin and doxorubicin. The median follow-up period was 33 months (range, 1–235 months). Grade 3 to 4 complications were seen in 127 (31%) of the 401 patients, and 9 patients (2%) died perioperatively.
The mean length of hospital stay was 22 days (standard deviation, 15 days). The overall median survival was 53 months (1–235 months), and 3- and 5-year survival rates were 60% and 47%, respectively. Four prognostic factors were independently associated with improved survival in the multivariate analysis:
- Epithelial subtype (P < .001).
- Absence of lymph node metastasis (P < .001).
- Completeness of cytoreduction (CC) scores of CC-0 or CC-1 (P < .001).
- HIPEC (P = .002).
This kind of analysis is subject to the biases of strong patient selection.Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with advanced malignant mesothelioma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.References
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- Butchart EG, Ashcroft T, Barnsley WC, et al.: The role of surgery in diffuse malignant mesothelioma of the pleura. Semin Oncol 8 (3): 321-8, 1981. [PUBMED Abstract]
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- Andreopoulou E, Ross PJ, O'Brien ME, et al.: The palliative benefits of MVP (mitomycin C, vinblastine and cisplatin) chemotherapy in patients with malignant mesothelioma. Ann Oncol 15 (9): 1406-12, 2004. [PUBMED Abstract]
- Mattson K, Holsti LR, Tammilehto L, et al.: Multimodality treatment programs for malignant pleural mesothelioma using high-dose hemithorax irradiation. Int J Radiat Oncol Biol Phys 24 (4): 643-50, 1992. [PUBMED Abstract]
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- de Perrot M, Feld R, Cho BC, et al.: Trimodality therapy with induction chemotherapy followed by extrapleural pneumonectomy and adjuvant high-dose hemithoracic radiation for malignant pleural mesothelioma. J Clin Oncol 27 (9): 1413-8, 2009. [PUBMED Abstract]
- Sugarbaker DJ, Mentzer SJ, DeCamp M, et al.: Extrapleural pneumonectomy in the setting of a multimodality approach to malignant mesothelioma. Chest 103 (4 Suppl): 377S-381S, 1993. [PUBMED Abstract]
- Markman M, Kelsen D: Efficacy of cisplatin-based intraperitoneal chemotherapy as treatment of malignant peritoneal mesothelioma. J Cancer Res Clin Oncol 118 (7): 547-50, 1992. [PUBMED Abstract]
- Markman M, Cleary S, Pfeifle C, et al.: Cisplatin administered by the intracavitary route as treatment for malignant mesothelioma. Cancer 58 (1): 18-21, 1986. [PUBMED Abstract]
- Rusch VW, Figlin R, Godwin D, et al.: Intrapleural cisplatin and cytarabine in the management of malignant pleural effusions: a Lung Cancer Study Group trial. J Clin Oncol 9 (2): 313-9, 1991. [PUBMED Abstract]
- Muers MF, Stephens RJ, Fisher P, et al.: Active symptom control with or without chemotherapy in the treatment of patients with malignant pleural mesothelioma (MS01): a multicentre randomised trial. Lancet 371 (9625): 1685-94, 2008. [PUBMED Abstract]
- Vogelzang NJ, Rusthoven JJ, Symanowski J, et al.: Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol 21 (14): 2636-44, 2003. [PUBMED Abstract]
- van Meerbeeck JP, Gaafar R, Manegold C, et al.: Randomized phase III study of cisplatin with or without raltitrexed in patients with malignant pleural mesothelioma: an intergroup study of the European Organisation for Research and Treatment of Cancer Lung Cancer Group and the National Cancer Institute of Canada. J Clin Oncol 23 (28): 6881-9, 2005. [PUBMED Abstract]
- Yan TD, Deraco M, Baratti D, et al.: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for malignant peritoneal mesothelioma: multi-institutional experience. J Clin Oncol 27 (36): 6237-42, 2009. [PUBMED Abstract]