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As noted in a recent , in the current age of re-writing therapeutic playbooks for most cancers, malignant pleural mesothelioma (MPM) has not been forgotten. Knowing MPM histologic subtype and staging remains imperative to direct therapy, though predictive biomarkers remain elusive. Volumetric tracking, F18-FDG PET/CT, and updated mRECIST criteria aid accurate staging and response assessments. While surgical approaches and outcomes remain limited (both numerically and geographically), radiation therapy (RT) and systemic options have increased.

While both neoadjuvant hypofractionated and adjuvant pleural hemithoracic intensity-modulated radiation therapy have improved survival, there's no clear benefit of prophylactic RT to prevent procedure-tract metastasis. Adjunct tumor-treating field devices bolster standard platinum-pemetrexed survival benefits per STELLAR. We're still pending a clear role for neoadjuvant and adjuvant immunotherapy.

Meanwhile in the palliative setting, dual immunotherapy is a FDA-approved first-line therapy for MPM per CheckMate 743. The combination of nivolumab and ipilimumab appears most impactful for biphasic and sarcomatoid histologies. BEATMeso, DREAM3R, and Canadian Cancer Trials Group studies investigate chemo-immunotherapy combinations. Numerous salvage immunotherapy trials have shown benefit whereas CAR-T efficacy has been limited.

A therapeutic void remains in the immune-refractory space.

Claire L. Hiles, MD, is a hematologist/oncologist at David Grant Medical Center at Travis AFB in California.

Read the review here and an interview about it here.