THIS DOCUMENT IS North of Scotland Cancer Network Clinical Management Guideline for Mesothelioma [Based on WOSCAN SCLC CMG with further extensive consultation within NOSCAN] UNCONTROLLED WHEN PRINTED Document Control (Original) Prepared by Approved by Dr Hannah Lord + changes advised to/by NMcL NOSCAN Lung Cancer MCN Issue date October 2014 Review date October 2017 Version V1.5 (20160630) Page 1 of 6
Diagnostic Pathway THIS DOCUMENT IS Clinical Management Guideline for Diagnosis and Evaluation Presentation with Pleural Effusion or Pleural Mass, previous Asbestos Exposure and clinical suspicion of Mesothelioma. CXR by GP, ideally with Thoracic CT pre-appointment. Patient seen within 2 weeks Day Pleural Effusion Pleural Mass Pleural US & Diagnostic +/- Therapeutic Pleural Aspiration, within 1/52 CT Clinic Review with Pleural Cytology Results Non Diagnostic Cytology Specific Dx other than Mesothelioma Treat as Appropriate Refer for Thoracoscopy allowing Pleural Biopsy, Drainage +/- Pleurodesis* - Medical Thoracoscopy (MT) if available. If not, consider referral to a MT centre or Surgical Thoracoscopy if the patient is fit for GA - Abram s Pleural Biopsy has a diagnostic sensitivity of 50% for Mesothelioma; it should not be used as a primary diagnostic test. It is acceptable only in the absence of MT being possible or available. Image Guided Pleural Biopsy 31 Specific Dx other than Mesothelioma Treat as Appropriate Results Clinic Review Possible Dx of Mesothelioma e.g. Suspicious Pathology Refer local Lung MDT +/- Mesothelioma MDT if needed Definite Dx of Mesothelioma Refer Mesothelioma MDT for pathology benchmarking, IMIG staging, easy access to clinical trials & IPC if required Consider: 1. Referral to Oncology if PS 0-2; if Platinum/Pemetrexed an option 2. Clinical Trials (including pain relief, systemic treatments and radical treatment options) 3. Referral to Palliative Care, particularly in patients with severe pain/advanced disease 4. Compensation, direct patients to the local Asbestos Action Group or other appropriate agency * Unlikely to be effective in patients with Trapped Lung early identification allows planning of an Indwelling Pleural Catheter if the patient develops symptomatic recurrent pleural effusion V1.5 (20160630) Page 2 of 6
THIS DOCUMENT IS Clinical Management Guideline for Therapeutic Management Surgery Surgical intervention may be considered a suitable clinical option for a small number of selected patients who are: (ECOG) PS 0-1 early stage disease only Systemic Therapy Palliative chemotherapy is presently licensed for patients with Mesothelioma who are: (ECOG) PS 0-2 (See page 4 for details) For a small cohort of patients who remain fit, 2 nd line chemo can be considered. (See page 4 for details) ECOG - East Coast Oncology Group PS - Performance Status V1.5 (20160630) Page 3 of 6
Clinical Management Guideline for Systemic Anti-Cancer Therapy Regimens THIS DOCUMENT IS Cisplatin Pemetrexed Indications: TBC Cisplatin 75mg/m² IV Infusion on Day 1 Pemetrexed 500mg/m² IV Infusion on Day 1 Repeat every 3 weeks/21 days Continue for a maximum of 6 cycles B12, Folic acid & Dexamethasone is required Note: Carboplatin [AUC* 5] IV Infusion can replace Cisplatin when clinically appropriate Note: If less than 6 months since last cycle, consider repeating Platinum and Pemetrexed. For patients who relapse before 6 months since their previous chemotherapy, consider single agent Vinorelbine Vinorelbine Indications: TBC Vinorelbine 30mg/m 2 IV Infusion on Day(s) 1, 8, 15, 22, 29 & 35 Repeat every 8 weeks/56 days Continue for a maximum of 2 cycles *AUC Area Under Curve (as per Cockcroft Gault equation) References SMC 192/05: Pemetrexed in combination with cisplatin for the treatment of chemotherapy-naïve patients with stage III/IV unresectable malignant pleural mesothelioma NICE (Multiple) Technology Appraisal Guidance No 135 Pemetrexed for the treatment of malignant pleural mesothelioma V1.5 (20160630) Page 4 of 6
THIS DOCUMENT IS Clinical Management Guideline for Post treatment and Follow Up This page is presently under further review. In meantime, excepting patients trial enrolled (who should be followed up according to protocol applicable), all patients following completion of initial therapy should be followed up according to local/board protocols V1.5 (20160630) Page 5 of 6
THIS DOCUMENT IS Clinical Management Guideline for TNM Staging System for Mesothelioma (AJCC-UICC) 7 th Edition Primary tumour T0 No evidence of primary tumour T1 Tumour involves ipsilateral parietal pleura T1a Tumour involves ipsilateral parietal (mediastinal, diaphragmatic) pleura with no involvement of the visceral pleura T1b Tumour involves ipsilateral parietal (mediastinal, diaphragmatic) pleura with focal involvement of visceral pleura T2 Tumour involves any of the ipsilateral pleural surfaces with at least one of the following: invasion of diaphragmatic muscle extension into the lung parenchyma T3 Describes locally advanced but potentially resectable tumour (i.e., it might be possible to remove it) Tumour involves any of the ipsilateral pleural surfaces with at least one of the following: invasion of the endothoracic fascia invasion into mediastinal fat solitary, completely resectable focus of tumor invading the soft tissues of the chest wall non-transmural involvement of the pericardium T4 Describes locally advanced technically unresectable tumour (i.e., it cannot be removed) Tumour involves any of the ipsilateral pleural surfaces with at least one of the following: diffuse or multifocal masses in the chest wall (with or without rib destruction) invasion through the diaphragm to the peritoneum direct extension to the contralateral pleura extension to mediastinal organs invasion into the spine extension through the internal surface of the pericardium (with or without a pericardial effusion or involvement of the myocardium) Regional lymph nodes (N) N0 No regional lymph node metastasis N1 Metastasis in the ipsilateral bronchopulmonary and/or hilar lymph nodes N2 Metastasis in the subcarinal lymph nodes, ipsilateral internal mammary, mediastinal lymph nodes, or the peridiaphragmatic lymph nodes N3 Metastases in the contralateral mediastinal, contralateral internal mammary, or hilar lymph nodes and/or the ipsilateral supraclavicular or scalene lymph nodes Distant metastases (M) M0 No distant metastases M1 Distant metastases present V1.5 (20160630) Page 6 of 6