NCARD researchers Professor Gary Lee and Dr Wee Loong (Melvin) Chin have co-authored a review outlining recent changes in the diagnosis and treatment of pleural mesothelioma.

Published in Current Opinion in Pulmonary Medicine, the paper was co-authored with Dr Deshawn Tan from Singapore General Hospital. It brings together recent evidence across diagnosis, surgery, systemic treatment and emerging therapies for clinicians working in a rapidly changing field.

The review highlights a shift towards earlier detection, less invasive management and more biologically informed treatment for pleural mesothelioma.

One important development is the formal recognition of mesothelioma in situ (MIS) as a pre-invasive form of the disease. For many years, pathologists observed abnormal mesothelial cells in some patients that did not meet the criteria for a diagnosis of mesothelioma. The 2021 World Health Organisation classification now recognises MIS as a distinct diagnostic category, supported by molecular markers that can indicate early malignant change.

This is significant because pleural mesothelioma is often diagnosed late and remains difficult to treat. The review notes that the time between MIS and invasive disease can span several years in some patients. In some cases, molecular abnormalities have been detected in pleural fluid samples collected years before a formal diagnosis of pleural mesothelioma was possible. These findings may support closer surveillance of people at higher risk, including people with a history of asbestos exposure.

The review also outlines a major change in thinking about radical surgery for pleural mesothelioma. Earlier approaches sometimes involved aggressive operations such as extrapleural pneumonectomy, which removes the affected lung and surrounding tissue. More recent randomised trial evidence, including the MARS and MARS-2 studies, has shown that radical surgical approaches can worsen survival and quality of life rather than improve outcomes.

At the same time, systemic treatment options have changed. Dual immunotherapy with nivolumab and ipilimumab is now incorporated as a first-line treatment option, particularly for sarcomatoid-containing pleural mesothelioma. The review also notes that adding pembrolizumab to standard pemetrexed and platinum chemotherapy provides a modest survival benefit.

Looking ahead, the review identifies several emerging areas of research, including targeted therapies, metabolic treatments, intrapleural therapies and AI-based diagnostic tools. Most remain under investigation, but together they reflect a broader move towards more personalised and less invasive care.

Read the full review in Current Opinion in Pulmonary Medicine: https://pubmed.ncbi.nlm.nih.gov/41982104/