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NCCN Guidelines for Patients



Malignant Pleural Mesothelioma, Version 1.2016

Surgical treatment is only recommended if the entire

tumor can be removed. Surgery is done if it can be

performed without excessive risk. If the whole tumor

or most of the disease can’t be removed by surgery,

then you will receive treatment with chemotherapy.

See page 27 for chemotherapy details and treatment


If surgery is possible, your doctor will then decide

which type of surgery is best for you. Surgery should

be performed by a board-certified thoracic surgeon.

A thoracic surgeon is a doctor who’s an expert in

operating on organs inside the chest.

There are two types of surgery for mesothelioma:



P/D (














P/D removes the tumor and the pleura affected by

the tumor. EPP removes both pleural layers, the

lung and diaphragm on the same side of the chest

as the tumor, and often the pericardium. During both

surgeries, lymph node sampling should be done to

assess if the cancer has spread to the lymph nodes

between your lungs. Lymph node sampling only

removes some of the nodes from a cluster. The goal

is to remove lymph nodes from at least 3 areas to be

examined in the mediastinum.

There is no well-designed research to show which

surgery is better in which circumstances. Your

doctors will recommend a surgery based on many

factors. They will consider your overall health, ability

to do activities, symptoms, cancer stage, and the

cell subtype of the mesothelioma cell. They will also

consider that the dangers of surgery are more likely

and more serious with EPP than with P/D. Ask your

treatment team for a list of all the dangers of the

surgery they recommend.

Adjuvant treatment

Adjuvant treatment is given after surgery to treat

any remaining cancer cells. Adjuvant treatment after

P/D is chemotherapy. If you had chemotherapy

before P/D, no adjuvant treatment is recommended.

See page 27 for a list of chemotherapy drugs

recommended for mesothelioma.

After EPP, radiation therapy is recommended as

adjuvant treatment. This is especially true for patients

with a PS 0–1, who also have good kidney function,

are not getting oxygen, and have no disease in

areas like the chest (the side without cancer) or

abdomen. Sequential chemotherapy with radiation

is recommended if you didn’t receive chemotherapy

before EPP surgery. Sequential treatment is when

one treatment is given after another rather than both

treatments being given at the same time. Radiation

therapy uses high-energy rays to treat cancer. The

rays damage a cell’s instructions for making and

controlling cells. This either kills the cancer cells or

stops new cancer cells from being made. Radiation

can also harm normal cells and cause side effects.

Ask your treatment team for a list of all the side

effects of radiation therapy.

Radiation will be given to the side of your chest

where the tumor was and other areas decided

by your radiation oncologist. For mesothelioma,

radiation is often given using a machine outside the

body. This method is called EBRT (









Before beginning radiation therapy, pictures of your

chest will be taken with a CT scan using contrast.

This process is called simulation. Your radiation

oncologist will use the pictures to decide the radiation

dose and to shape the radiation beams. Beams are

shaped with computer software and hardware added

to the radiation machine. PET scans may also be

used for radiation treatment planning (simulation).


Treatment guide

Stage I–III epithelioid or mixed mesothelioma