Mesothelioma Flashcards
When do you offer urgent CXR? (2 week)
As per NICE NG12:
Offer urgent CXR in those 40 years or over with 2 or more of the following/ 1 or more +smoking hx or +asbestos hx
-cough
-fatigue
-SOB
-chest pain
-weight loss
-appetite loss
Over 50 years with:
-clubbing chest signs consistent with pleural disease
How is mesothelioma staged?
Eighth edition AJCC/UICC staging for malignant pleural mesothelioma:
TX - Primary tumour cannot be assessed
T0 - No evidence of primary tumour
T1 - Tumour limited to the ipsilateral
parietal±visceral± mediastinal±diaphragmatic pleura
T2 - Tumour involving each of the ipsilateral pleural surfaces (parietal,
mediastinal, diaphragmatic and visceral pleura) with at least one of
the following features:
►Involvement of diaphragmatic muscle
►Extension if tumour from visceral pleura into the underlying pulmonary parenchyma
T3 Describes locally advanced but potentially resectable tumour. Tumour
involving all of the ipsilateral pleural surfaces (parietal, mediastinal,
diaphragmatic and visceral pleura) with at least one of the following
features:
►Involvement of endothoracic fascia
►Extension into the mediastinal fat
►Solitary, completely resectable focus of tumour extending into the
soft tissues of the chest wall
►Non-transmural involvement of the pericardium
T4 Describes locally advanced technically unresectable tumour. Tumour
involving all of the ipsilateral pleural surfaces (parietal, mediastinal,
diaphragmatic and visceral pleura) with at least one of the following
features:
►Diffuse extension or multifocal masses of tumour in the chest
wall, with or without associated rib destruction
►Direct transdiaphragmatic extension of tumour to peritoneum
►Direct extension of tumour to the contralateral pleura
►Direct extension of tumour to mediastinal organs
►Direct extension of tumour into the spine
►Tumour extending through to the internal surface of the
pericardium with or without pericardial effusion, or tumour
involving the myocardium
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastases
N1 Metastases in the ipsilateral
bronchopulmonary, hilar or mediastinal
(including the internal mammary, peridiaphragmatic, pericardial fat
pad or intercostal lymph nodes) lymph nodes
N2 Metastases in the contralateral mediastinal, ipsilateral or contralateral
supraclavicular lymph nodes
M0 No distant metastasis
M1 Distant metastasis present
What is the optimum initial imaging for suspected mesothelioma and why?
CT thorax with contrast as this optimizes pleural evaluation
Why is PET-CT not recommended post talc slurry and what other previous medical history is relevant when requesting?
Talc slurry can cause false positive. TB pleuritis and inflammatory disorders of the pleura, previous parapneumonic effusions can also cause this.
What are possible false negatives with PET-CT?
Small volume tumours and those with a low proliferative index, for instance, early stage epithelioid mesothelioma
When would you offer PET-CT in mesothelioma?
When excluding distant metastasis would change management
What are the ICH requirements for a diagnosis of mesothelioma?
ICH recommended in both biopsy and cytology preparations (not cytology alone).
For confirmed diagnosis requires:
2 positive mesothelial markers and
2 negative adenocarcinoma markers
What are some of the positive mesothelial markers for ICH diagnosis?
Calretinin
Cytokeratin 5/6 (CK5/6)
CAM 5.2
Vimentin
HBME-1
WT-1
Desmin
p53
CD90
D-240
EMA
What are the negative adeno markers for ICH diagnosis?
M0C31
BerEp4
CEA
TTF-1
Leu-M1
CD15
B72.3
Claudin-4
What are the recommendations for use of biomarkers in mesothelioma?
-Should not be offered in isolation as a diagnostic test
-Consider biomarker testing in patients with suspicious cytology who are not fit for more invasive tests
-DO not routinely offer biomarker testing to predict treatment response or survival
-Do not offer to screen for MPM
What prognostic scores are available?
EORTC
CALGB
modified Glasgow prognostic score
LENT - if pleural effusion present
Decision tree analysis - used most in routine clinical practice
What is the recommendation for symptomatic pleural effusion in MPM?
Offer talc slurry or poudrage or IPC taking informed by patient choice
What are the surgical recommendations in MPM?
- Do not offer VATS-PP over talc pleurodesis
-DO not offer extra pleural pneumonectomy
-Do not offer extended pleurectomy decortication outside of clinical trial
What are the systemic anti-cancer therapy options?
When PS 0-1, offer cisplatin with pemetrexed.
Ralitrexed an alternative to pemetrexed.
Do not offer pemetrexed or vorinostat as second line
Where cisplatin contraindicated offer carboplatin or if there is an adverse risk
What are the radiotherapy recommendations?
DO not offer:
Prophylactic chest wall tracts
Hemithorax
Pre or post operative
Consider:
Palliative radiotherapy for localized pain
What is the staging for tumour involving parietal, visceral, diaphragmatic, mediastinal pleura with exentsion to lung parenychyma and involvement of endothoracic fascia. Lymph nodes are found contralateral hilar region.
T3N2M0
What are the known risk factors for meso?
- male preponderance
- most commonly from occupational exposure
- occupations: production of asbestos sheets,
brake and clutch linings, construction/demolition work,
dock and ship yard workers, electricians, plumbers and
launderers - brown and blue asbestos exposure
- rare cases associated with BAP1 gene breast ca
SUV threshold to define malignant v benign pleural disease?
SUV >2 sensitivity of 88%–100% and specificity of
88%–92%
What was MAPS?
trial with pem+cisplatin v bevacizumab
pem/cisplatin = longer survival 18months v 16
SUV threshold to define malignant v benign pleural disease?
SUV >2 sensitivity of 88%–100% and specificity of
88%–92%
What is EMPHASIS?
trial done to look at chemo pemetrexed/cisplatin v control (cisplatin alone)
-3 month survival benefit
- time to progression was longer (5.7 v 3.9)
-response rate was 41% v 17%
How does pemetrexed work?
inhibits thymidylate synthase, thereby preventing the formation
of precursor pyrimidine nucleotides
What was MS01?
trial comparing:
1. active symptom Mx
2. active symptom Mx + MVP (mitomycin, cisplatin and
vinblastine)
3. active symptom Mx + vinorelbine
- no survival benefit
- no QOL differences
What was MAPS?
trial with pem+cisplatin v bevacizumab
pem/cisplatin = longer survival 18months v 16
