Clinical cases in Malignant Pleural Mesothelioma: Adherence to the ESMO Clinical Practice Guidelines

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1 Clinical cases in Malignant Pleural Mesothelioma: Adherence to the ESMO Clinical Practice Guidelines Wieneke Buikhuisen The Netherlands Cancer Institute Amsterdam The Netherlands

2 Case (1) Male, 56 year Hypertension Shortness of breath for two months Fatigue Discrete right-sided chest pain

3 Case (2) No weight loss Quit smoking 2003, 30 PY Asbestos exposure: yes Profession: since 1967 carpenter Medication: enalapril

4 Physical examination Vital, PS 1, RR 140/85 mmhg Thorax: normal chest movements Lungs: decreased breath sounds right side

5 Courtesy of The Netherlands Cancer Institute, Amsterdam

6 Courtesy of The Netherlands Cancer Institute, Amsterdam

7 Courtesy of The Netherlands Cancer Institute, Amsterdam

8 Diagnostic procedure Laboratory: no abnormalities Pleural fluid examination: suggestive for mesothelioma Courtesy of The Netherlands Cancer Institute, Amsterdam

9 Q 1: The diagnosis mesothelioma (MPM) can best be made on: 1. A history of asbestos exposure in combination with typical image of CT-scan 2. Cytology examination of pleural fluid 3. Histology: fine needle biopsies 4. Histology: during thoracoscopy (biopsies of normal and abnormal pleura)

10 Q 1: The diagnosis mesothelioma (MPM) can best be made on: 1. A history of asbestos exposure in combination with typical image of CT-scan 2. Cytology examination of pleural fluid 3. Histology: fine needle biopsies 4. Histology: during thoracoscopy (biopsies of normal and abnormal pleura)

11 Q 2: What do you consider the optimal staging approach? 1. Using the International Staging System (2010) 2. All patients should undergo VATS and PET scan for diagnosis and staging 3. Depending on the choice of treatment staging procedures should be less or more extensive

12 Q 2: What do you consider the optimal staging approach? 1. Using the International Staging System (2010) 2. All patients should undergo VATS and PET scan for diagnosis and staging 3. Depending on the choice of treatment staging procedures should be less or more extensive

13 Case continued Our patient underwent a medical thoracoscopy where both parietal pleura, and diaphragm were affected by tumour. The lungs did not seem to be affected. Multiple biopsies were taken confirming the diagnosis of malignant mesothelioma, epithelial type. Parietal pleura lung thoracoscopy Courtesy of The Netherlands Cancer Institute, Amsterdam

14 Q 3: What is your preferred treatment for this patient? 1. Active support of care: there is no evidenced based treatment for MPM 2. Chemotherapy consisting of platinum and pemetrexed or raltitrexed 3. Radical surgery (EPP) followed by RT 4. Targeted agents (mtor and PI3K inhibitors)

15 Q 3: What is your preferred treatment for this patient? 1. Active support of care: there is no evidenced based treatment for MPM 2. Chemotherapy consisting of platinum and pemetrexed or raltitrexed 3. Radical surgery (EPP) followed by RT 4. Targeted agents (mtor and PI3K inhibitors)

16 Case continued Participation in randomised phase 2 study Cisplatin and pemetrexed combined with VEGF TKI Axitinib or placebo Thoracoscopy before and after 3 cycles Pleurectomy/Decortication

17 Thoracoscopy Parietal pleura Parietal pleura lung Lung Before After Courtesy of The Netherlands Cancer Institute, Amsterdam

18 Follow-up at 9 months This CT scan shows progression of the disease, with pleural fluid and chest wall infiltration Courtesy of The Netherlands Cancer Institute, Amsterdam

19 Follow-up at 9 months This CT scan shows invasion of the rib Courtesy of The Netherlands Cancer Institute, Amsterdam

20 Q 4: What is your opinion on the role for radiotherapy in MPM? 1. Radiotherapy would have prevented parital seeding along the drainage tracts 2. Radiotherapy is indicated after pleurectomy/decortication 3. Palliative radiotherapy aimed at pain relief may be considered in case of painful chest wall infiltration

21 Q 4: What is your opinion on the role for radiotherapy in MPM? 1. Radiotherapy would have prevented parital seeding along the drainage tracts 2. Radiotherapy is indicated after pleurectomy/decortication 3. Palliative radiotherapy aimed at pain relief may be considered in case of painful chest wall infiltration

22 THANK YOU!

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