Induction or adjuvant chemotherapy for radical multimodality therapy

The use of radical surgery, with either extrapleural pneumonectomy (EPP) or extended pleurectomy decortication (EPD), as part of multimodality treatment in malignant pleural mesothelioma (MPM) has been shown to prolong survival outcomes. The platinum/pemetrexed doublet is used as standard first line chemotherapy as it is the only treatment proven in a randomized trial setting to give a survival advantage. It is unclear as to the optimal timing of chemotherapy, either in the neoadjuvant or immediate adjuvant setting. Some oncologists also favour reserving this standard therapy for the time at which the disease progresses following debulking surgery. Recently published guidelines from the American Society of Clinical Oncology (ASCO) recommend the use of chemotherapy as part of multimodality treatment, but do not stipulate at which point in the treatment regime this should be given. Further research is required to determine the optimal timing of chemotherapy in the context of the multimodality treatment of MPM.