Chinese clinical diagnosis and treatment guidelines for malignant pleural mesothelioma (2021 version), 5 minutes get the main points!

Pleural mesothelioma is a derived from skin cells or other parts of rare tumor, which is derived from the pleural about 81 %, other portionsbits comprises peritoneal, pericardial and the like tunica vaginalis testis
.

Malignant pleural mesothelialtumors (when MPM) and more newly diagnosedwith advanced, treatment difficulties, poor efficacy, median overall survival timewas about1year, 5-year survival rate is about 10 % cure rare cases

Pleural mesothelioma is a derived from skin cells or other parts of rare tumor, which is derived from the pleural about 81 %, other portions bits comprises peritoneal, pericardial and the like tunica vaginalis testis

1.

(1) Incidence rate

2020 the global number of new cases of malignant mesothelioma is 30870 cases, accounting for global emerging cancer 0.
2 % and the number of deaths was 26278 cases, accounting for the number of global cancer deaths 0.
3 %
.

2020 the global number of new cases of malignant mesothelioma is 30870 cases, accounting for global emerging cancer 0.
2 % and the number of deaths was 26278 cases, accounting for the number of global cancer deaths 0.
3 %
.

2019 Annual Report of Chinese cancer registration, reporting 2016 in the Tumordata registries to 682 , a total included in the Quality Control Registry 487 , covering population of 3.
8 billion and annual report, 2016 years, Chinathe number of new cases of mesothelioma are 583 embodiment, whereinthe MPM [diseases internationalclassification( the ICD 10 )coding for theC 45.
0 ]of the number of new cases is 330.
Example, the incidence rate of about 0.
86 / 100 million and standardized incidence rate ( Segi ' S worldcommunity standard population) to 0.
53 / 100 million and no significant trend of incidence variation of; the MPM death 215 Example mortality rate of about 0.
56 / 100 million and standardized The incidence ( Segi ' S world community standard population) was 0.
53 / 100 million
.

2019 Annual Report of Chinese cancer registration, reporting 2016 in the Tumor data registries to 682 , a total included in the Quality Control Registry 487 , covering population of 3.
8 billion and annual report, 2016 years, China the number of new cases of mesothelioma are 583 embodiment, wherein the MPM [diseases international classification ( the ICD 10 ) coding for the C 45.
0 ] of the number of new cases is 330.
Example, the incidence rate of about 0.
86 / 100 million and standardized incidence rate ( Segi ' S world community standard population) to 0.
53 / 100 million and no significant trend of incidence variation of; the MPM death 215 Example mortality rate of about 0.
56 / 100 million and standardizedThe incidence ( Segi ' S world community standard population) was 0.
53 / 100 million
.

(2) Inducing factors

(2) Inducing factors

1 , Asbestos: 20 Century 70 's, the United States began to reduce asbestos mining, MPM incidence decreased, but the United States reported MPM incidence of cases and number of deaths was still higher than in other countries of the world
.

Russia, China, Ba Xihe Canada is the major producer of asbestos

1 , Asbestos: 20 Century 70 's, the United States began to reduce asbestos mining, MPM incidence decreased, but the United States reported MPM incidence of cases and number of deaths was still higher than in other countries of the world

2 , ionizing radiation: Ionizing radiation may also cause mesothelioma hair health, such as MPM partially received cape radiation field radiation therapy of Hodgkin 's lymphoma of a patient suffering often lymphoma 2 primary cancer

3.

4 , gene mutations: gene MPM play for the pathogenesis of certain use, such as the BRCA1 -associated protein .

Second, the diagnosis Second, diagnosis diagnosis

(1) Basic principles of diagnosis

(1) Basic principles of diagnosis

1 , clinical features: MPM Common symptoms include shortness of breath, chest pain, cough cough, insomnia, fatigue, loss of appetite, and weight loss
.

MPM Pro clinical symptoms is often more serious than other tumors, MPM patients when the lesion is localized by that is obvious shortness of breath occurs, chest pain

1 , clinical features: MPM Common symptoms include shortness of breath, chest pain, cough cough, insomnia, fatigue, loss of appetite, and weight loss

2 , examination: screening found that pleural thickening, recommended enhanced chest screening CT examination and pathology or cytology to confirm the diagnosis, monitoring can also be measured soluble mesothelin-related peptide levels of soluble mesothelin-related peptide levels may be associated with MPM is related

3.
Differential diagnosis: MPM mainly needs to be differentiated from benign pleural disease and other malignant pleural metastases (such as lung cancer, sarcoma and other solid tumors, etc.
)
.
Imaging examination has a suggestive effect, but it is difficult to diagnose
.
Pathological or cytological examination is the main method of differential diagnosis
.

(2) Pathological diagnosis

(2) Pathological diagnosis

MPM is a heterogeneous group of tumors, including pathology .
3 Species major subtypes, epithelioid type, bipolar type and sarcomatoid, the pathological diagnosis should be given said main histological subtypes diagnosis
.
For MPM pathological examination technique mainly immunological staining, fluorescence original hybridization analysis, RNA sequencing, comparative genomic hybridization arrays
.

MPM is a heterogeneous group of tumors, including pathology .
3 Species major subtypes, epithelioid type, bipolar type and sarcomatoid, the pathological diagnosis should be given said main histological subtypes diagnosis
.
For MPM pathological examination technique mainly immunological staining, fluorescence original immunoassay hybridization analysis, RNA sequencing, comparative genomic hybridization arrays
.

1 , inspection: improving patient clinical specimens for inspection when required to provide information, such as occupational exposure history, imaging findings, cancer history and treatment history and so on
.
Imperfect clinical information will affect the initial judgment, specimen processing, sampling procedures and subsequent auxiliary analysis
.

1 , inspection: improving patient clinical specimens for inspection when required to provide information, such as occupational exposure history, imaging findings, cancer history and treatment history and so on
.
Imperfect clinical information will affect the initial judgment, specimen processing, sampling procedures and subsequent auxiliary analysis
.

2 , sample: a sample for the diagnosis of various types, including thoracic mirror surgical specimens, specimens of open surgery, CT -guided core needle biopsies present, core needle biopsy specimen under ultrasound guidance, guided chest thoracoscopic living subject specimen, fine needle Puncture cell specimens and pleural fluid exfoliated cell specimens
.
Pleural biopsy is usually performed by thoracoscopy or percutaneous needle biopsy guided by CT or ultrasound , and is the main method of sample acquisition
.
Of the patient to surgery may be recommended for potentially hole in the chest incision endoscopy
.
Fine needle biopsy and cytology detected may appear larger sampling bias, often false negative, less accurate, seldom regulations and recommended FNA cytology detected as a sample according to the diagnostic data
.

2 , sample: a sample for the diagnosis of various types, including thoracic mirror surgical specimens, specimens of open surgery, CT -guided core needle biopsies present, core needle biopsy specimen under ultrasound guidance, guided chest thoracoscopic living subject specimen, fine needle Puncture cell specimens and pleural fluid exfoliated cell specimens
.
Pleural biopsy is usually performed by thoracoscopy or percutaneous needle biopsy guided by CT or ultrasound , and is the main method of sample acquisition
.
Of the patient to surgery may be recommended for potentially hole in the chest incision endoscopy
.
Fine needle biopsy and cytology detected may appear larger sampling bias, often false negative, less accurate, seldom regulations and recommended FNA cytology detected as a sample according to the diagnostic data
.

3 , pathological type: The , 2015 World Health Organization ( the WHO ) chest film swelling tumor sub class standard registration, the MPM histologic subtypes including epithelioid type, sarcomatoid, double phase (hybrid) type, wherein the epithelial type Most commonly, the diagnosis of biphasic MPM requires both epithelioid and sarcomatoid components to be> 10 %
.
2015 edition of WHO's pathological classification criteria for pleural mesothelioma
.

3 , pathological type: The , 2015 World Health Organization ( the WHO ) chest film swelling tumor sub class standard registration, the MPM histologic subtypes including epithelioid type, sarcomatoid, double phase (hybrid) type, wherein the epithelial type Most commonly, the diagnosis of biphasic MPM requires both epithelioid and sarcomatoid components to be> 10 %
.
2015 edition of WHO's pathological classification criteria for pleural mesothelioma
.

4.
Cytology: MPM is often accompanied by pleural effusion at the first diagnosis.
Pleural effusion cytology is the first diagnostic procedure that is easy to perform
.
Cells but low detection sensitivity learning and sarcomatoid MPM cells not normally off down to serous cavities, is not routinely recommended as pleural fluid cytology is the basis for diagnosis
.
But can not obtain the pleural lesions, if a sufficient number of mesothelioma cells and is representative, may be prepared by immunohistochemistry and fluorescence in situ hybridization Preparation of cell division wax block analysis, and clinical, imaging and (or ) surgical examination performed MPM 's diagnosis
.
When the cell morphology showed different degrees of atypia (typically low level) but can not determine the degree of malignancy, the term may be used " SARS type mesothelial cell proliferation " , but insufficient for the diagnosis of the MPM
.

4.
Cytology: MPM is often accompanied by pleural effusion at the first diagnosis.
Pleural effusion cytology is the first diagnostic procedure that is easy to perform
.
Cells but low detection sensitivity learning and sarcomatoid MPM cells not normally off down to serous cavities, is not routinely recommended as pleural fluid cytology is the basis for diagnosis
.
But can not obtain the pleural lesions, if a sufficient number of mesothelioma cells and is representative, may be prepared by immunohistochemistry and fluorescence in situ hybridization Preparation of cell division wax block analysis, and clinical, imaging and (or ) surgical examination performed MPM 's diagnosis
.
When the cell morphology showed different degrees of atypia (typically low level) but can not determine the degree of malignancy, the term may be used " SARS type mesothelial cell proliferation " , but insufficient for the diagnosis of the MPM
.

5.
Immunohistochemistry: Immunohistochemistry can differentiate MPM and its different subtypes from other malignant tumors or pleural metastases , with high diagnostic accuracy and specificity
.
Support diagnostic MPM mainly markers include Calretinin, to CK5 / .
6, a WT1, Mesothelin and D 2-40 , and support the diagnosis of primary lung cancer markers include TTF ⁃ .
1, Napsin A, carcinoma embryonic anti original ( carcinoembryonic Antigen, of CEA ), BerEP4 and Claudin4 and so on .

5.
Immunohistochemistry: Immunohistochemistry can differentiate MPM and its different subtypes from other malignant tumors or pleural metastases , with high diagnostic accuracy and specificity
.
Support diagnostic MPM mainly markers include Calretinin, to CK5 / .
6, a WT1, Mesothelin and D 2-40 , and support the diagnosis of primary lung cancer markers include TTF ⁃ .
1, Napsin A, carcinoma embryonic anti original ( carcinoembryonic Antigen, of CEA ), BerEP4 and Claudin4 and so on .

6 , molecular detection: MPM common variant gene BAP1 group because, of CDKN2A ( of P16) gene and the NF2 gene
.
BAP1 is the most common mutant gene of MPM .
Germline BAP1 mutations are related to other malignant tumors such as uveal melanoma and renal cell carcinoma, collectively referred to as BAP1 tumor syndrome
.

6 , molecular detection: MPM common variant gene BAP1 group because, of CDKN2A ( of P16) gene and the NF2 gene
.
BAP1 is the most common mutant gene of MPM .
Germline BAP1 mutations are related to other malignant tumors such as uveal melanoma and renal cell carcinoma, collectively referred to as BAP1 tumor syndrome
.

(3) Imaging diagnosis

(3) Imaging diagnosis

There is currently no evidence that low-dose spiral CT screening for high-risk groups (people with a history of asbestos exposure ) can reduce MPM mortality.
Therefore, low-dose spiral CT screening for MPM is
not routinely recommended .
Firstly recommended thoracoabdominal enhanced CT clinical staging, breast MRI for the assessment of chest wall, spine, diaphragm or vascular lesions higher sensitivity , especially for iodine contrast agents contraindications patient may select breast MRI
.
The PET ⁃ CT mainly for surgical patients stage evaluation, and only using CT compared, the PET ⁃ CT of Ⅱ period (min respectively of 77% and 100%, P <0.
01) and Ⅲ stage (respectively 75% and 100%, P< 0.
01) The specificity of MPM staging is higher
.
But another In one study, the PET ⁃ CT of N1 period and T4 of MPM spirit low sensitivity (respectively 38% and 67%)
.

There is currently no evidence that low-dose spiral CT screening for high-risk groups (people with a history of asbestos exposure ) can reduce MPM mortality.
Therefore, low-dose spiral CT screening for MPM is
not routinely recommended .
Firstly recommended thoracoabdominal enhanced CT clinical staging, breast MRI for the assessment of chest wall, spine, diaphragm or vascular lesions vessel higher sensitivity , especially for iodine contrast agents contraindications patient may select breast MRI
.
The PET ⁃ CT mainly for surgical patients stage evaluation, and only using CT compared, the PET ⁃ CT of Ⅱ period (min respectively of 77% and 100%, P <0.
01) and Ⅲ stage (respectively 75% and 100%, P< 0.
01) The specificity of MPM staging is higher
.
But anotherIn one study, the PET ⁃ CT of N1 period and T4 of MPM spirit low sensitivity (respectively 38% and 67%)
.

Three, treatment

Three, treatment three, treatment three, treatment

When the diagnosis of MPM is highly suspected , a multidisciplinary team with experience in MPM diagnosis and treatment should be evaluated as soon as possible, so as to effectively intervene in MPM as soon as possible .
The main interventions include surgery, put therapy and systemic chemotherapy .
Can use triple therapy, namely chemotherapy, surgery, and hemi-thoracic radiotherapy .
Studies have shown that the median survival time of patients receiving complete triple therapy is 20 to 29 months .

When the diagnosis of MPM is highly suspected , a multidisciplinary team with experience in MPM diagnosis and treatment should be evaluated as soon as possible, so as to effectively intervene in MPM as soon as possible .
The main interventions include surgery, put therapy and systemic chemotherapy .
Can use triple therapy, namely chemotherapy, surgery, and hemi-thoracic radiotherapy .
Studies have shown that the median survival time of patients receiving complete triple therapy is 20 to 29 months .

(1) Surgical treatment

(1) Surgical treatment

Surgery in MPM controversial role , but for Ⅰ ~ Ⅲ A stage MPM patients with resected possible resistance, surgical treatment can be assessed by multidisciplinary team discussed later
.
For Ⅲ B ~ IV of MPM, surgery is not recommended
.
Despite the research studies show that, Ⅰ ~ Ⅱ of sarcomatoid MPM patients from the surgical treatment may be obtained overall survival ( the OS) to extend, but the hand around operative complications and mortality than non sarcomatoid MPM patients who, therefore, Surgery is not recommended
.
Generally not recommended cytoreductive surgery, unless it can be safely removed most of the tumor, reducing tumor negative charge helps postoperative treatment
.

Surgery in MPM controversial role , but for Ⅰ ~ Ⅲ A stage MPM patients with resected possible resistance, surgical treatment can be assessed by multidisciplinary team discussed later
.
For Ⅲ B ~ IV of MPM, surgery is not recommended
.
Despite the research studies show that, Ⅰ ~ Ⅱ of sarcomatoid MPM patients from the surgical treatment may be obtained overall survival ( the OS) to extend, but the hand around operative complications and mortality than non sarcomatoid MPM patients who, therefore, Surgery is not recommended
.
Generally not recommended cytoreductive surgery, unless it can be safely removed most of the tumor, reducing tumor negative charge helps postoperative treatment
.

(2) Medical treatment

(2) Medical treatment

1 , chemotherapy

1 , chemotherapy

(1) First-line chemotherapy: Chemotherapy can be used for patients with stage III B to IV and unresectable stage I to III A patients
.
MPM 's first first-line treatment option pemetrexed + cisplatin or pemetrexed + cisplatin + bevacizumab
.

(1) First-line chemotherapy: Chemotherapy can be used for patients with stage III B to IV and unresectable stage I to III A patients
.
MPM 's first first-line treatment option pemetrexed + cisplatin or pemetrexed + cisplatin + bevacizumab
.

(2) Second-line chemotherapy: For patients who have not used pemetrexed in first-line therapy , second-line therapy is recommended
.
Line containing pemetrexed in patients with plug after treatment failure, can still be used again pemetrexed, especially for the young, PS good score, no progression after first-line therapy students keep a patient for a long time
.

(2) Second-line chemotherapy: For patients who have not used pemetrexed in first-line therapy , second-line therapy is recommended
.
Line containing pemetrexed in patients with plug after treatment failure, can still be used again pemetrexed, especially for the young, PS good score, no progression after first-line therapy students keep a patient for a long time
.

2 , immunotherapy

2 , immunotherapy

(1) first-line immune therapy: an open- label, randomized multi-center Ⅲ clinical trial designed to evaluate satisfied Wu Lee , especially monoclonal antibody adalimumab + Iraq horses comparison to standard chemotherapy for untreated MPM study, the results show , satisfied that Wu Yi Li You mAb + match adalimumab compared with standard chemotherapy (pemetrexed + cisplatin or carboplatin) significantly reduced not resectable MPM risk of death of 26 % sodium Wu Li You single anti-Iraq match + The median OS of patients in the lumumab treatment group was 18.
1 months, which was better than 14.
1 months in the chemotherapy group .

(1) first-line immune therapy: an open- label, randomized multi-center Ⅲ clinical trial designed to evaluate satisfied Wu Lee , especially monoclonal antibody adalimumab + Iraq horses comparison to standard chemotherapy for untreated MPM study, the results show , satisfied that Wu Yi Li You mAb + match adalimumab compared with standard chemotherapy (pemetrexed + cisplatin or carboplatin) significantly reduced not resectable MPM risk of death of 26 % sodium Wu Li You single anti-Iraq match + The median OS of patients in the lumumab treatment group was 18.
1 months, which was better than 14.
1 months in the chemotherapy group .

(2) Second-line and later-line immunotherapy: The exploration of immunotherapy in MPM is first carried out in the second-line therapy
.
A multi-center, randomized, non-controlled phase II study ( n= 125 ) to evaluate the efficacy of nivolumumab ± ipilimumab in the second-line treatment of MPM .
The results showed that nivolumumab + ipilimumab The median OS of the patients in the group was 15.
9 months, and the 1- year survival rate was 58 %.
The median OS of the patients in the nivolumab monotherapy group was 11.
9 months, and the 1- year survival rate was 49 %; PD - L1 was highly expressed positively correlated with the overall response rate, particularly in the PD ⁃ Ll expression ≥25 % based
.

(2) Second-line and later-line immunotherapy: The exploration of immunotherapy in MPM is first carried out in the second-line therapy
.
A multi-center, randomized, non-controlled phase II study ( n= 125 ) to evaluate the efficacy of nivolumumab ± ipilimumab in the second-line treatment of MPM .
The results showed that nivolumumab + ipilimumab The median OS of the patients in the group was 15.
9 months, and the 1- year survival rate was 58 %.
The median OS of the patients in the nivolumab monotherapy group was 11.
9 months, and the 1- year survival rate was 49 %; PD - L1 was highly expressed positively correlated with the overall response rate, particularly in the PD ⁃ Ll expression ≥25 % based
.

3.
Targeted therapy

3.
Targeted therapy

Genomics studies have shown that no clear driver gene mutations have been detected in the tumor tissues of MPM patients, and the inactivation of tumor suppressor genes dominates, including the inactivation of CDKN2A / 2B, BAP1, NF2, LAST2 and other genes
.
Correct because the inactivation of tumor suppressor genes than targeting swollen tumor gene driven hard, after, MPM therapy targeted mostly failed
.
At present , clinical trials of CDK4 / 6 inhibitors are underway in MPM patients whose CDKN2A gene mutations cause loss of function .

Genomics studies have shown that no clear driver gene mutations have been detected in the tumor tissues of MPM patients, and the inactivation of tumor suppressor genes dominates, including the inactivation of CDKN2A / 2B, BAP1, NF2, LAST2 and other genes
.
Correct because the inactivation of tumor suppressor genes than targeting swollen tumor gene driven hard, after, MPM therapy targeted mostly failed
.
At present , clinical trials of CDK4 / 6 inhibitors are underway in MPM patients whose CDKN2A gene mutations cause loss of function .

4.
Other treatments

4.
Other treatments

Oncolytic virus is a new type of anti-tumor treatment strategy, especially for MPM.
Due to the operability of intrapleural injection, the oncolytic virus treatment of MPM shows a promising application
.

Oncolytic virus is a new type of anti-tumor treatment strategy, especially for MPM.
Due to the operability of intrapleural injection, the oncolytic virus treatment of MPM shows a promising application
.

(3) Radiotherapy and other physical therapy

(3) Radiotherapy and other physical therapy

1 , radiation therapy: Although traditionally considered MPM to radiotherapy resistance, but studies have shown that radiation therapy can have a positive therapeutic effect
.
2000 Since the height of the proper application of radiotherapy techniques such as intensity modulated release therapy ( IMRT), so that research studies can optimize the entire half-completed high-dose radiation therapy of the chest
.
But put therapy is generally not recommended for use alone as a multidisciplinary treatment strategy part of the strategy
.

1 , radiation therapy: Although traditionally considered MPM to radiotherapy resistance, but studies have shown that radiation therapy can have a positive therapeutic effect
.
2000 Since the height of the proper application of radiotherapy techniques such as intensity modulated release therapy ( IMRT), so that research studies can optimize the entire half-completed high-dose radiation therapy of the chest
.
But put therapy is generally not recommended for use alone as a multidisciplinary treatment strategy part of the strategy
.

2 , other physical therapy: tumor treated by a portable electric type non-invasive device for local treatment, attached to the chest by a disposable sensor that generates a low-intensity ( .
1 ~ .
3 V / cm & lt) , intermediate rate ( 100 ~ 300 kHz ) , 2 th side direction between the alternating variable electric field
.

2 , other physical therapy: tumor treated by a portable electric type non-invasive device for local treatment, attached to the chest by a disposable sensor that generates a low-intensity ( .
1 ~ .
3 V / cm & lt) , intermediate rate ( 100 ~ 300 kHz ) , 2 th side direction between the alternating variable electric field
.

(4) Principles of comprehensive treatment of MPM for different stages and pathological types

(4) Principles of comprehensive treatment of MPM for different stages and pathological types

1.
According to the MPM staging of the eighth edition of the Joint Committee on Cancer of the United States for treatment
.

1.
According to the MPM staging of the eighth edition of the Joint Committee on Cancer of the United States for treatment
.

(1) Primary tumor ( T) : Tx: The primary tumor cannot be assessed; T0 : There is no evidence of the primary tumor; T1 : The primary tumor is limited to the ipsilateral pleura, with or without visceral pleura, mediastinal pleura, diaphragmatic pleural involvement; T2 : ipsilateral pleura tumor invasion and a surface portion (parietal pleura, longitudinal partition pleura, diaphragm pleura, visceral pleura) , and comprising at least one to the next characteristics: invasion and diaphragm; dirty by pleural invasion and lung parenchyma; T3 : Board late portion but potentially possible tumor resection
.
Tumor invasion and ipsilateral chest of each surface of the membrane (parietal pleura, mediastinal pleura, diaphragm pleura, visceral chest film) , and includes at least one of the following characteristics: invasion of the chest cavity and fascia; invasion and mediastinal fat; single, can completely resected tumor foci invasion and chest wall soft tissue; nontransmural pericardial invasion; T4 : technical locally advanced unresectable tumors
.
The tumor invades all surfaces of the ipsilateral pleura (parietal pleura, mediastinal pleura, diaphragmatic pleura, visceral pleura) , and has at least one of the following characteristics: diffuse infiltration of the chest wall or multiple lesions, with or without rib destruction; direct Invades the abdominal cavity through the diaphragm; directly invades the contralateral pleura; directly invades the mediastinal organs; directly invades the spine; penetrates the inner surface of the
pericardium , with or without pericardial effusion, or invasion of the myocardium .
(2) Regional lymph nodes (N) : Nx: The status of lymph node metastasis cannot be Assessment; N0 : no regional lymph node metastasis; N1 : ipsilateral bronchial, lung, hilar or mediastinum (including ipsilateral internal mammary, peridiaphragmatic, pericardial fat pad, intercostal lymph nodes) lymph node metastasis; N2 : contralateral mediastinum, same Lateral or contralateral supraclavicular lymph node metastasis
.
(3) Distant metastasis (M) : M0 : No distant metastasis; M1 : Distant metastasis
.

(1) Primary tumor ( T) : Tx: The primary tumor cannot be assessed; T0 : There is no evidence of the primary tumor; T1 : The primary tumor is limited to the ipsilateral pleura, with or without visceral pleura, mediastinal pleura, diaphragmatic pleural involvement; T2 : ipsilateral pleura tumor invasion and a surface portion (parietal pleura, longitudinal partition pleura, diaphragm pleura, visceral pleura) , and comprising at least one to the next characteristics: invasion and diaphragm; dirty by pleural invasion and lung parenchyma; T3 : Board late portion but potentially possible tumor resection
.
Tumor invasion and ipsilateral chest of each surface of the membrane (parietal pleura, mediastinal pleura, diaphragm pleura, visceral chest film) , and includes at least one of the following characteristics: invasion of the chest cavity and fascia; invasion and mediastinal fat; single, can completely resected tumor foci invasion and chest wall soft tissue; nontransmural pericardial invasion; T4 : technical locally advanced unresectable tumors
.
The tumor invades all surfaces of the ipsilateral pleura (parietal pleura, mediastinal pleura, diaphragmatic pleura, visceral pleura) , and has at least one of the following characteristics: diffuse infiltration of the chest wall or multiple lesions, with or without rib destruction; direct Invades the abdominal cavity through the diaphragm; directly invades the contralateral pleura; directly invades the mediastinal organs; directly invades the spine; penetrates the inner surface of the
pericardium , with or without pericardial effusion, or invasion of the myocardium .
(2) Regional lymph nodes (N) : Nx: The status of lymph node metastasis cannot beAssessment; N0 : no regional lymph node metastasis; N1 : ipsilateral bronchial, lung, hilar or mediastinum (including ipsilateral internal mammary, peridiaphragmatic, pericardial fat pad, intercostal lymph nodes) lymph node metastasis; N2 : contralateral mediastinum, same Lateral or contralateral supraclavicular lymph node metastasis
.
(3) Distant metastasis (M) : M0 : No distant metastasis; M1 : Distant metastasis
.

2.
The principle of comprehensive treatment of surgically resectable MPM

2.
The principle of comprehensive treatment of surgically resectable MPM

(1) for resectable Ⅰ ~ Ⅲ A Non sarcomatoid MPM patients, selected by experienced Thoracic Surgeons P / D or EPP, is intended to cut visible lesions, adjuvant chemotherapy may be used surgery and intraoperative radiation therapy
.

(1) for resectable Ⅰ ~ Ⅲ A Non sarcomatoid MPM patients, selected by experienced Thoracic Surgeons P / D or EPP, is intended to cut visible lesions, adjuvant chemotherapy may be used surgery and intraoperative radiation therapy
.

(2) Adjuvant chemotherapy and hemithoracic IMRT are recommended after P / D , and adjuvant chemotherapy and hemithoracic radiotherapy are recommended after EPP .
Not routinely push recommended immediate postoperative prevention of radiotherapy, but did not receive adjuvant chemotherapy for postoperative patients, prophylactic radiotherapy can reduce surgical risk transfer path .
Push recommended radiation dose is 45 ~ 60 Gy / 1.
8 ~ 2 Gy, for R2 resected patients, using> 60 in the case where the adjacent tissue tolerance Gy agent amount .

(2) Adjuvant chemotherapy and hemithoracic IMRT are recommended after P / D , and adjuvant chemotherapy and hemithoracic radiotherapy are recommended after EPP .
Not routinely push recommended immediate postoperative prevention of radiotherapy, but did not receive adjuvant chemotherapy after surgery for prevention patients, prophylactic radiotherapy can reduce surgical risk transfer path .
Push recommended radiation dose is 45 ~ 60 Gy / 1.
8 ~ 2 Gy, for R2 resected patients, using> 60 in the case where the adjacent tissue tolerance Gy agent amount .

(3) adjuvant chemotherapy and radiotherapy opportunity should MDT group team for discussion and decision

(3) adjuvant chemotherapy and radiotherapy opportunity should MDT group team for discussion and decision

3 , unresectable MPM comprehensive treatment principles

3 , unresectable MPM comprehensive treatment principles

(1) the initial unresectable Ⅰ ~ Ⅲ A Non meat neoplastic MPM patients, surgery may attempt rows neoadjuvant chemotherapy treatment, sequential postoperative radiotherapy
.
For patients with inoperable indeed, can line systemic chemotherapy, treatment principles and programs see part of medical treatment
.

(1) the initial unresectable Ⅰ ~ Ⅲ A Non meat neoplastic MPM patients, surgery may attempt rows neoadjuvant chemotherapy treatment, sequential postoperative radiotherapy
.
For patients with inoperable indeed, can line systemic chemotherapy, treatment principles and programs see part of medical treatment
.

(2) For Ⅲ B, IV of sarcomatoid or pathological type MPM and not suitable for surgery of MPM patients, generally depending on the patient, the line chemotherapy treatment or support
.

(2) For Ⅲ B, IV of sarcomatoid or pathological type MPM and not suitable for surgery of MPM patients, generally depending on the patient, the line chemotherapy treatment or support
.

4 , MPM common systemic therapy program MPM first-line systemic treatment of choice program see
.
MPM common line after systemic treatment regimen, the treatment of choice for the training pemetrexed (for first-line treatment of patients with uncontrolled pemetrexed use, push line containing Pei patient pemetrexed programs; recommended second-line therapy use after treatment failure It can still be used again pemetrexed, especially for in light, PS score good, progression-free survival for a long time after first-line treatment of patients) , Nivolumab ± Ipilimumab ( If a line does not make use) , Pembrolizumab, other alternatives It is vinorelbine and gemcitabine .

4 , MPM common systemic therapy program MPM first-line systemic treatment of choice program see
.
MPM common line after systemic treatment regimen, the treatment of choice for the training pemetrexed (for first-line treatment of patients with uncontrolled pemetrexed use, push line containing Pei patient pemetrexed programs; recommended second-line therapy use after treatment failure It can still be used again pemetrexed, especially for in light, PS score good, progression-free survival for a long time after first-line treatment of patients) , Nivolumab ± Ipilimumab ( If a line does not make use) , Pembrolizumab, other alternatives It is vinorelbine and gemcitabine .

Original source

Original source

Chinese Medical Association multidisciplinary cancer treatment professional committee .
China malignant pleural mesothelioma Clinical Practice Guidelines (2021 edition) .
Chinese Journal of Cancer 2021 Nian 4 month second 43 Volume 4 Qi

Chinese Medical Association multidisciplinary cancer treatment professional committee clinics .
China malignant pleural mesothelioma Clinical Practice Guidelines (2021 edition) .
Chinese Journal of Cancer 2021 Nian 4 month second 43 Volume 4 Qi in this message