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Intrapleural delivery is an effective way of delivering chemotherapy in patients with MPM. Intrapleural chemotherapy can be particularly effective early, when the disease is limited to the pleural surface. However, the current data with the adjuvant intrapleural chemotherapy is inconclusive and should not be routinely used except in the setting of clinical trials. Our results with intrapleural L-NDDP are very encouraging and warrant further studies either as a neoadjuvant or an adjuvant to debulking surgery or in combination with intravenous chemotherapy.

The mainstay of unresectable malignant mesothelioma remains the control of patients’ symptoms. Most patients survive only a few months. Talc is the single most commonly used agent for pleurodesis either as slurry or by poudrage. The use of talc is not without complications. Cytokines hold promise, but additional work and reduced costs are necessary. The search for an ideal agent for pleurodesis continues.

The sequence of induction chemotherapy, extrapleural pneumonectomy, and adjuvant radiotherapy is certainly feasible in selected patients with mesothelioma. This sequence can be completed as planned in a high proportion of patients. In this limited experience, induction chemotherapy does not appear to be increasing the perioperative mortality and complication risks of extrapleural pneumonectomy. Whether this multimodality sequence is superior to the strategy of surgery first followed by chemotherapy and radiotherapy will require further study and the experience of other centers.

The number of cases of malignant pleural mesothelioma diagnosed each year is increasing and it is expected to increase at least until the year 2010. The diagnosis of this disease is often difficult. There is no current standard of care for pleural mesothelioma and only a few trials using the combination of surgery and adjuvant therapies appear to have demonstrated any significant impact on the expected course of the disease. Newer diagnostic and treatment techniques are needed to improve survival in these patients with MPM. This chapter discussed the role of one of the adjuvant treatments, photodynamic therapy, in the management of mesothelioma.

Combined therapy appears to be an effective method for the treatment of peritoneal mesothelioma. It can be performed safely and with acceptable morbidity. The WCI has reported a median overall survival of 67 months with a projected 3-year survival rate of 64% in 68 patients treated with various combinations of cytoreduction, CHPP, and intraperitoneal chemotherapy. The NCI has evaluated 49 patients who received combined therapy for peritoneal mesothelioma and found a median overall survival of 92 months with a projected overall 3-year survival of 59%. In both cases the outcomes are remarkably better than those in most previous reports of treatments for peritoneal mesothelioma, though these results need to be interpreted with caution, due to the short follow-up and selected study population. The essential elements of combined therapy remain to be defined. The individual components of the therapy, including cytoreduction, intraoperative chemotherapy and hyperthermia, postoperative intraperitoneal chemotherapy, and perioperative intravenous chemotherapy, have been studied in various combinations and not in isolation. Further study is needed to define the optimal combination of therapies and to determine which patients may benefit most from the combined therapy approach. Ongoing trials are addressing these questions.