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Pleural mesothelioma

What's new

The American Society of Clinical Oncology (ASCO) has updated its guidelines for the diagnosis and management of pleural mesothelioma. The term malignant pleural mesothelioma has been renamed pleural mesothelioma, as all benign and premalignant mesothelial entities (now renamed mesothelioma in situ) no longer include "mesothelioma" in their name. Germline testing is recommended for all patients, as most have germline mutations, most commonly in the BAP1 gene. Surgical cytoreduction with either extrapleural pneumonectomy or lung-sparing options is recommended only for highly selected patients with favorable prognostic features. Tunneled pleural catheters or pleurodesis is suggested for patients ineligible for maximal surgical cytoreduction. First-line systemic therapy options include ipilimumab plus nivolumab (immunotherapy) and pembrolizumab plus pemetrexed with platinum-based chemotherapy (chemoimmunotherapy). The addition of bevacizumab to chemotherapy is suggested for epithelioid histology. .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of pleural mesothelioma are prepared by our editorial team based on guidelines from the American Society of Clinical Oncology (ASCO 2025,2018), the British Thoracic Society (BTS 2023,2018), the European Society of Medical Oncology (ESMO 2022), the Spanish Association of Medical Oncology (SEOM 2021), and the European Society for Radiotherapy and Oncology ...
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Screening and diagnosis

Indications for screening: as per ESMO 2022 guidelines, insufficient evidence to recommend screening for early diagnosis of MPM in patients exposed to asbestos.
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  • Diagnosis

Classification and risk stratification

Staging: as per ASCO 2025 guidelines, recognize that the AJCC/UICC staging classification may be challenging to apply to clinical staging for both T and N components and may be imprecise in predicting prognosis, and upstaging may occur at surgery for patients with clinical stage I/II disease.
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  • Prognosis

Diagnostic investigations

Occupational history: as per ESMO 2022 guidelines, elicit occupational history with emphasis on asbestos exposure in patients with suspected MPM.
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  • Diagnostic imaging (general principles)

  • Diagnostic imaging (X-ray)

  • Diagnostic imaging (ultrasound)

  • Diagnostic imaging (CT)

  • Diagnostic imaging (MRI)

  • Diagnostic imaging (PET/CT)

  • Imaging for staging

  • Germline testing

  • Biomarkers

Diagnostic procedures

Thoracentesis
As per ASCO 2025 guidelines:
Perform an initial thoracentesis in patients presenting with symptomatic pleural effusions and send pleural fluid for cytologic examination to assess for possible mesothelioma.
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Consider using cytologic diagnosis for treatment decisions in selected patients in whom tissue is not available or cannot be obtained.
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  • Contralateral thoracoscopy

  • Mediastinoscopy

  • Laparoscopy

  • Biopsy

  • Histopathology

Medical management

General principles: as per BTS 2023 guidelines, decide on the best treatment modality based on patient choice.
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  • Expectant management

  • Systemic therapy, general principles

  • Systemic therapy, first-line

  • Systemic therapy, second-line

Therapeutic procedures

Radiotherapy: as per ASCO 2025 guidelines, offer adjuvant radiotherapy in patients who have resection of intervention tracts found to be histologically positive.
B
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  • Pleurodesis

  • Indwelling pleural catheter

  • Intracavitary therapies

Surgical interventions

Indications for surgical cytoreduction: as per ASCO 2025 guidelines, do not offer surgical cytoreduction routinely in all patients based solely on anatomic resectability.
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  • Macroscopic complete resection

  • Extended pleural decortication

  • Palliation of pleural effusion

Patient education

General counseling
As per BTS 2018 guidelines:
Provide accurate and understandable information to patients and carers about compensation for MPM.
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Provide patients with MPM and their carers the opportunity to discuss concerns regarding their disease.
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Follow-up and surveillance

Assessment of treatment response: as per ASCO 2025 guidelines, insufficient evidence to support the use of biomarkers to predict response to therapy in patients with PM.
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