In 2009 experts came together to set out guidelines for the management of malignant pleural mesothelioma. These were unchanged for over ten years but have now been updated.

Task force

A task force of experts in Europe was formed and included members from the European Respiratory Society (ERS), the European Society of Thoracic Surgeons (ESTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Radiotherapy and Oncology (ESTRO).

The experts reviewed studies carried out between 2009 and 2018 to update the recommendations on diagnosis, staging, monitoring and treating pleural mesothelioma.

Diagnosis and pathology

Biopsies are still deemed to be the best practice for diagnosing pleural mesothelioma, with samples being collected through a thoracoscopy or image guided needle biopsy.

The current standard pathology staining techniques are not infallible and do not work in around 10% of cases. It is now recommended that as well as the standard staining tests, testing is done for mesothelioma biomarkers such as BAP-1 or CDKN2A.


The previous recommendations used mesothelioma subtype, tumour volume and the patient’s overall health to help assess a patient’s prognosis and likely response to treatment. The new recommendations still advise using these but also suggests that other potential factors should be recorded for use in future research and clinical trials.


Chemotherapy and clinical trials are seen as the best treatments for pleural mesothelioma. The experts confirmed that clinical trials allow patients to have combination treatments. As the research into combination treatments is still relatively new there is limited information about what the best combination treatment is.

Best practices are a guideline

The best practice recommendations are not a set of rules for doctors to stick to rigidly, however they do provide a good starting point. Patients react differently to different treatments and it is a case of finding what works best for each patient, ensuring best quality of life throughout.

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Opitz, I, et al, “ERS/ESTS/EACTS/ESTRO Guidelines for the Management of Malignant Pleural Mesothelioma”, May 25, 2020, European Journal of Cardiothoracic Surgery, Epub ahead of print,

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