Catálogo de publicaciones - libros

The distinction between benign pleural plaques and malignancy can usually be made by simple radiographic findings. When there is uncertainty, surgical biopsy, preferably by a VATS approach, should be performed. Biopsy should be performed separately from the definitive resection because immunohistochemistry and electron microscopy are usually required to distinguish benign pleural lesions from diffuse malignant pleural mesothelioma. Benign or malignant solitary fibrous tumors, when pedunculated and free of adjacent structures, may be easily treated by VATS surgical excision. Careful evaluation of adjacent structures and the entire pleural cavity is essential to minimize the risk of recurrence. All solitary fibrous tumors, regardless of a benign or malignant histology, must be approached with caution because of the risk of local recurrence. The initial treatment of choice for solitary fibrous tumors or pleural tumors mimicking this lesion is en bloc surgical resection. Patients should be followed closely postoperatively and recurrences managed by extensive surgical resection with or without adjuvant radiation.

Most patients with malignant mesothelioma are candidates for systemic chemotherapy during the course of their disease, but no standard regimen has been established. Several phase II single-agent and combination chemotherapy studies have been performed over the past two decades. Although the true impact of chemotherapy in mesothelioma remains to be determined, agents with consistent antitumor activity include the platinum agents and the antifolates. Phase II studies of combination chemotherapy are associated with higher response rates but not necessarily longer median survivals. Recent data from a large randomized phase III clinical trial established the superiority of cisplatin/pemetrexed compared to cisplatin alone. Data from this and other ongoing studies will help establish standard chemotherapy regimens for mesothelioma and provide a basis for combination studies with molecular agents and incorporation of these regimens into multimodality treatment approaches.

The role of chemotherapy in malignant mesothelioma has changed since the late 1990s with the emergence of new active regimens, improved image reporting, and high-quality data from large multicenter randomized studies. A review of the literature indicates increasing reports of efficacy of second-line chemotherapy in selected fit patients. The activity of pemetrexed and cisplatin in the first-line setting and the apparent value of post-study chemotherapy within the context of that phase III study have confirmed the sensitivity of some mesotheliomas to chemotherapy. Those data, in turn, have opened the door for exploration of chemotherapy or other novel therapies in the second-line setting for malignant mesothelioma. Last, novel phase II studies are required, indeed vital, to determine active agents and combinations in this setting. Careful analysis of the results of such studies by risk/prognostic group assignment and prior response duration will need to be done. Ultimately the most promising agent(s) will need to be evaluated in a randomized comparison against the current standard of best supportive care.