BTS statement on mesothelioma

Statement on malignant mesothelioma in the United Kingdom : Statement on malignant mesothelioma in the United Kingdom Thorax 2001;56:250-265


Statement on malignant mesothelioma (MM) in the United Kingdom: 2007 : Statement on malignant mesothelioma (MM) in the United Kingdom: 2007 British Thoracic Society Standards of Care Committee


Membership of the BTS Working Party : Membership of the BTS Working Party Prof. M G Britton, Consultant Chest Physician, St Peter’s Hospital, Chertsey, Surrey KT16 0PZ Ms L Darlison Consultant Nurse, Glenfield Hospital Leicester Dr J Entwisle Consultant Radiologist Glenfield Hospital Leicester. Dr M A Greenstone, Consultant Physician, Castle Hill Hospital, Cottingham, Hull HU16 5JQ Dr M Hetzel, Consultant Physician, Bristol Royal Infirmary, Bristol BS2 8HW Dr C Higgs, Medical Director, Dorothy House Hospice, Winsley, Bradford-on-Avon, Wiltshire BA15 2LE. Dr N Maskell Consultant Physician Bristol BA15 2LE Dr M F Muers, Consultant Physician, The General Infirmary at Leeds, Leeds,West Yorkshire LS1 3EX Dr R Rudd, Consultant Physician, London Chest Hospital, London E2 9JX. Prof T Treasure Consultant Thoracic Surgeon Guys Hospital London Dr J Wiggins (Chairman and Editor of Statement), Consultant Physician, Wexham Park Hospital, Wexham, Slough, Berkshire SL2 4HL Additional contributions were obtained from: Dr A Darnton Epidemiology and Medical Statistics Unit, Health and Safety Executive, Magdalen House, Stanley Precinct, Bootle L20 3QZ Dr M Snee Consultant Medical Oncologist Leeds Dr M Sheaff Consultant Histopathologist, St Bartholomew’s Hospital London Ms C Tan Specialist Registrar Guys Hospital London


Sections with little or no change : Sections with little or no change Introduction Epidemiology; predicted rise in incidence has occured Clinical features; consideration of MM in any patient with pleural fluid or thickening re-emphasised Prognosis


Diagnostic strategy : Diagnostic strategy Key points The importance of a detailed occupational history cannot be overemphasised. Any patient in whom mesothelioma is suspected should be promptly referred to a respiratory physician for further assessment. Pathological confirmation of the diagnosis is recommended, unless the patient is frail or has extremely advanced disease. Negative pleural biopsy and cytological results do not exclude mesothelioma and should lead to further investigation. CT scanning plays a key role in the diagnosis of mesothelioma


Diagnostic imaging : Diagnostic imaging Fast track Xray reports to MDT Rapid access to CT Image- guided biopsy Limited role of MRI PET scanning Radiological staging


PATHOLOGY : PATHOLOGY Pathological diagnosis emphasised Key role of immunohistochemistry Submission for second opinion encouraged


Management; general points : Management; general points Key role of MDT Prompt involvement of specialist nurse Need for provision of information Holistic care Organisation on care; MDT composition and ‘specialist MDT’


Surgery : Surgery EPP; MARS trial Meso VATS Key points There are no randomised control trials to establish the role of radical surgery. Radical surgery should only be considered when there is a positive diagnosis of epithelioid mesothelioma, resectable disease and fitness for surgery. Surgery should only be performed in centres where there experience in performing extrapleuropneumonectomies. The limited evidence available has reported surgical results only as part of a multimodality treatment strategy.


The management of pleural effusion : The management of pleural effusion Key points Early pleurodesis is a key aim for symptom control and prevention of the development of a trapped lung. Thoracoscopy is an extremely useful tool for obtaining diagnostic pleural tissue as well allowing pleural fluid drainage and talc poudrage. Calibrated talc is the pleurodesis agent of choice Indwelling pleural catheters are useful for symptom control in cases of trapped lung or where chemical pleurodesis has failed. 


Radiotherapy : Radiotherapy ·        Prophylactic radiotherapy reduces chest wall implantation following invasive procedures. ·        Palliative radiotherapy provides pain relief in about half of all patients. ·        Palpable masses respond to radiotherapy in about half of all patients. ·        Breathlessness and superior vena caval obstruction rarely respond to radiotherapy.


Chemotherapy : Chemotherapy Key points ·        Several chemotherapeutic agents can reduce tumour bulk and help symptoms. The combination of pemetrexed and cisplatin significantly prolongs survival compared with cisplatin alone. ·        All patients with mesothelioma should have the opportunity to discuss the pros and cons of chemotherapy with either an oncologist or a respiratory specialist experienced in the use of chemotherapy for MM ·        There are no published trials comparing either survival or symptom control in patients treated with chemotherapy or best supportive care. The results of the first such trial, BTS MSO-1, are expected by mid–2007. ·        Further clinical trials of chemotherapy should be encouraged.


New approaches : New approaches VEGF receptor antagonists; bevacizumab Anti-tumour ribonuclease; ranpirnase Proteosome inhibitor; bortezomib Immunotherapy Gene therapy


Supportive and palliative care : Supportive and palliative care Remains crucial; remains most important aspect of care? Lung cancer (or MM) specialist nurse


Role of CNS : Role of CNS  Key points. Clinical nurse specialists are pivotal to meeting patients’ specialist supportive care needs.   Patients with MM and their carers should have access to a lung cancer CNS   Complex communication pathways need to be maintained   Providing information to people with cancer and carers should be an ongoing process   Patients and their carers should be advised that, following a diagnosis of MM, entitlement to some benefits and allowances is automatic   The lung cancer CNS acts as the key worker facilitating the pathway of care for the patient and the family throughout the illness     Physical, psychological, social and spiritual assessment may need to be repeated at several key times during the disease pathway   Patient preference is particularly relevant when making treatment decisions about MM   Timely access to the health care team is vital    


Medico-legal aspects : Medico-legal aspects IIDB; Industrial Injuries Advisory Council initiatives Common law; Barker v Corus, Compensation Act 2006