Diagnostic and therapeutic strategy for malignant pleural mesothelioma in 2008. An update

Malignant pleural mesothelioma (MPM) is a rare tumour, secondary to professional asbestosis exposure. MPM incidence is rising since the late sixties and this increase will continue till 2020-2030, with curently 800 to 1000 new cases in France. Molecular carcinogenesis of MPM is still poorly understood but gene alterations of NF2, c-met, WT1 RASSF1, and p16, have been described. These genes are involved in cell invasion and motility, cell division and apoptosis control. The histological diagnosis remains critical since the morphology of this neoplasm is extremely variable, but immunohistochemical analyses have been precisely described by the French Mesopath Group. The clinical diagnosis relies on thoracos-copy and large pleural biopsy. The therapeutic strategy always includes the irradiation of drainage channels or pleural punctures with 3 x 7 Grays within the four weeks following these procedures. Rarely, in carefully selected patients, extensive extra-pleural pneumonectomy can be performed. The recommended first-line chemotherapy is based on a doublet of pemetrexed and cisplatin that has demonstrated in a phase III setting, an overall increase in survival and improvement of quality of life when compared to a cisplatin-based monotherapy. Antiangiogenic agents such as bevacizumab could be of interest but they have to be tested in randomized phase III trials.