Second Italian Consensus Conference on Malignant Pleural Mesothelioma: State of the art and recommendations

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Abstract

Malignant pleural mesothelioma (MPM) is a relevant public health issue. A large amount of data indicate a relationship between mesothelioma and asbestos exposure. MPM incidence has considerably and constantly increased over the past two decades in industrialized countries and is expected to peak in 2010–2020. In Italy, the standardized incidence rate in 2008 was 3.6 and 1.3 per 100,000 in men and women respectively, with wide differences from one region to another. The approach to this disease remains difficult and complex in terms of pathogenic mechanism, diagnosis, staging and treatment thus an optimal strategy has not yet been clearly defined. The Second Italian Multidisciplinary Consensus Conference on Malignant Pleural Mesothelioma was held in Turin (Italy) on November 24–25, 2011: recommendations on MPM management for public health institutions, clinicians and patients are presented in this report.

Introduction

Malignant pleural mesothelioma (MPM) nowadays can no longer be considered an uncommon malignant disease, as the extensive use of asbestos since the 1950s has led to an important increase in both incidence and mortality rates. Incidence has considerably and constantly increased over the past two decades in the industrialized countries and is expected to peak in 2010–2020. The approach to this disease remains difficult and complex in terms of diagnosis, staging and treatment and an optimal strategy has not yet been clearly defined. The First Italian Consensus Conference on Malignant Pleural Mesothelioma was held in Bologna (Italy) in 2008.1

The Second Italian Multidisciplinary Consensus Conference on Malignant Pleural Mesothelioma was held in Turin (Italy) in November 2011 and endorsed by AIOM (Italian Association of Medical Oncology).

Section snippets

Methods

The consensus adopted the GRADE approach (http://www.gradeworkinggroup.org/) to design and build up the recommendations. In the planning phase, each panel defined some relevant questions, chose the endpoints and ranked their importance. The methodological group organized the electronic search, selected the relevant evidence according to the panel indications, produced summary of findings, tables and rated the quality of evidence according to GRADE.2 These profiles represented the basis for the

Summary of epidemiology, public health and surveillance evidence

According to the Italian Registry of Malignant Mesothelioma (ReNaM), in 2008 MPM incidence was 3.6 cases per 100,000 person-years in men and 1.3 in women. Corresponding rates for peritoneal MM were 0.24 and 0.12 and 1422 incident cases of MM (all sites) were observed.3

In Italy median survival of MPM cases diagnosed in 1990–2001 was 9.8 months and less than 10% were alive after 3 years, similarly to other countries.[4], [5], [6]

The occurrence of MPM showed an increasing trend in recent decades,

Summary of pathology and laboratory evidence

The current reference diagnostic method is mainly based on light microscopic examination of tissue samples stained with conventional hematoxylin–eosin and immunohistochemical stains. The pathological recognition of MPM may pose a difficult differential diagnosis with both pleural benign asbestos-induced disease, and pleural metastases of adenocarcinoma, generally from lung or breast. Metastatic cancers greatly outnumber MPM. The molecular carcinogenesis of MPM is incompletely understood.[61],

Non-invasive diagnostic procedures

The sole chest-X ray finding of the pleural plaques does not require additional investigations, whereas recurrent unilateral pleural effusion not related to any know etiology should be further characterized by contrast-enhanced computed tomography (CT). However, CT underestimates early chest wall invasion, peritoneal involvement, and has well-known limitations in nodal metastatic evaluation. Magnetic resonance imaging (MRI) is superior to CT, both in the differentiation of malignant from benign

First-line chemotherapy

Approximately 85–90% of patients with MPM present with locally advanced unresectable disease at diagnosis and such patients rely on palliative treatment. The response rate and survival are generally greater for combinations than for single-agent regimens, for platinum-containing regimens than for non-platinum-containing combinations and also for those regimens containing anti-folate rather than other molecules.

The only available randomized clinical trial comparing active symptom control (ASC)

Summary of surgical evidence

Previous Italian Expert Opinions 1 focused on the need for correct staging definition of malignant pleural mesothelioma (MPM), identifying ITMIG T1a-b and T2 as potential subsets amenable to surgery with an intent to cure. Thoracoscopy represents the diagnostic modality which enables the surgeon to fully understand the feasibility of a pleural vs pleuro-pulmonary resection.[121], [122], [123], [124], [125], [126], [127], [128], [129], [130], [131], [132], [133], [134], [135], [136], [137], [138]

Summary of radiotherapy evidence

Radiotherapy is widely used in the treatment of patients with MPM, as an integral part of trimodality therapy for early stage disease, in the prophylaxis of port-site recurrence and in the palliative setting.[150], [151] In spite of these possible different clinical indications, there is limited evidence regarding the precise role of radiotherapy.

Comparative studies in MPM investigating radiotherapy versus no-radiotherapy intervention as control arm are available only for prophylactic

Contributors

The following epidemiologists, public health and occupational physicians, pathologists, radiologists, pneumologists, nuclear medicine physicians, surgeons, medical oncologists and radiation oncologists have taken part in the Second Italian Consensus Conference of Malignant Pleural Mesothelioma.

Conflict of Interest

Disclose any actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations that could inappropriately influence their work.

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