Malignant mesothelioma is an insidious
neoplasm arising from the mesothelial surfaces of the pleural and peritoneal cavities, the pericardium, or the tunica vaginalis. A total of 80% of all cases are pleural in origin. The predominant cause of
malignant mesothelioma is inhalational exposure to
asbestos, although evidence is increasing to support the hypothesis that simian virus-40 virus plays a role in
cocarcinogenesis. Immunohistochemical markers such as
calretinin, WT-1, and
cytokeratin 5/6 are becoming established diagnostic markers. Preliminary data suggests that a soluble form of
mesothelin could serve as a
serum marker for established and early cases of
mesothelioma. Positron emission tomography with 18-fluorodeoxyglucose in conjunction with computed tomograhy scanning has improved preoperative imaging and staging. Prognostic factors have been identified and verified. Negative indicators include
thrombocytosis, high leukocyte counts, poor performance status, and nonepithelial histology. For the first time, there is now evidence that some treatments are increasing the quality and quantity of life for patients with
mesothelioma.
Chemotherapy, with the new multi-targeted
antifolate drug
Pemetrexed, combined with
cisplatin, has shown superior survival rates in a large phase III trial when compared to
cisplatin alone. High-dose
intensity-modulated radiotherapy when administered after extrapleural
pneumonectomy has resulted in excellent local control. Multimodality treatment programs that combine surgical cytoreduction with novel forms of
radiation therapy and more effective
chemotherapy combinations may offer significant increases in survival for certain subgroups of
mesothelioma patients. Innovative palliative approaches have proved successful in alleviation of the significant symptoms experienced by many
mesothelioma patients. Experimental treatments such as
immunotherapy and gene therapy present a window of hope for all
mesothelioma patients, and in the future, may be combined with 'standard
therapy' in multimodality protocols. Patients with adequate performance status should be enrolled into clinical trials where possible. Over the past decade, significant advances have been made on several fronts that have improved the ability to diagnose a stage, define prognosis, and treat
malignant pleural mesothelioma.