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 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 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).
Stage I–III epithelioid or mixed mesothelioma