Mesothelioma

Mesothelioma is a rare but aggressive cancer of the mesothelium — the thin tissue layer that lines the body's internal cavities. Most cases are directly caused by past exposure to asbestos, often decades before any symptoms appear. Understanding this disease can help patients and families navigate diagnosis, treatment decisions, and legal rights.

Table of Contents

  1. What Is Mesothelioma?
  2. Asbestos: The Primary Cause
  3. Types of Mesothelioma: Pleural, Peritoneal, and Rare Forms
  4. Histological Subtypes: Epithelioid, Sarcomatoid, Biphasic
  5. Symptoms: Late Presentation and Why It Matters
  6. Diagnosis: Biopsy, Imaging, Biomarkers
  7. Staging and Prognosis
  8. Treatment: Surgery, Chemotherapy, Immunotherapy
  9. Occupational History and Legal Rights
  10. Key Research Papers
  11. Featured Videos

1. What Is Mesothelioma?

Mesothelioma is a malignancy arising from mesothelial cells — the specialized cells that form the mesothelium, a smooth tissue layer that lines and lubricates the surfaces of the body's major cavities and organs. The mesothelium covers the lungs (the pleura), the abdominal organs (the peritoneum), and the heart (the pericardium). When these cells turn cancerous, the resulting tumor is called mesothelioma.

About 3,000 new cases are diagnosed in the United States each year. The disease most commonly strikes people in their late 60s to early 70s — the median age at diagnosis is 69 to 72 years. One of mesothelioma's most striking and medically important features is its extraordinarily long latency period: the time between initial asbestos exposure and the appearance of cancer is typically 20 to 50 years, the longest latency period of any known occupational cancer. This means that most people diagnosed today were exposed to asbestos in the 1960s, 1970s, or 1980s, long before they had any reason to suspect a problem.

It is important to distinguish mesothelioma from lung cancer. Lung cancer arises from the bronchial epithelium — the cells lining the airways inside the lungs. Mesothelioma arises from the mesothelial cells on the outer surface of the lung and chest wall. They are biologically different diseases with different treatments, and a history of heavy asbestos exposure is far more predictive of mesothelioma than of primary lung cancer (though asbestos exposure does also raise lung cancer risk).

Because mesothelioma is rare and its symptoms are vague and slow to develop, most patients are diagnosed at an advanced stage — which is one of the core challenges of the disease. Research into earlier detection and more effective treatments has accelerated significantly in the past two decades.

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2. Asbestos: The Primary Cause

Asbestos is a group of naturally occurring silicate minerals that were widely used in construction, manufacturing, and shipbuilding throughout the 20th century because of their extraordinary fire resistance, tensile strength, and insulating properties. There are two main categories of asbestos fibers, and they are not equally dangerous:

Chrysotile (white asbestos): The serpentine (curly, flexible) form of asbestos. It was the most widely used type, appearing in building insulation, floor tiles, cement pipes, brake pads, and textiles. Its curly fibers are more readily cleared by the lungs' defense mechanisms and are generally considered less potent than the amphibole forms, though chronic high-level exposure still causes disease.

Amphibole asbestos (crocidolite and amosite): The needle-shaped (straight, brittle) fibers. Crocidolite (blue asbestos) and amosite (brown asbestos) are far more strongly associated with mesothelioma. Their needle-like shape allows them to penetrate deeply into the pleura, where they become permanently embedded because macrophages — the immune cells responsible for clearing inhaled debris — cannot engulf and remove them. This permanent residence triggers decades of chronic inflammation.

The biological mechanism unfolds over years: asbestos fibers embedded in the pleura trigger persistent macrophage activation and release of reactive oxygen species and inflammatory cytokines. This chronic inflammatory environment damages DNA in mesothelial cells. Key genetic changes accumulate: mutation or deletion of the tumor suppressor gene CDKN2A (p16/p14ARF), loss of function of NF2 (encoding the merlin protein, a tumor suppressor), BAP1 (BRCA1-associated protein-1) mutations, and disruption of TP53 (p53) pathways. These molecular changes, building over decades, drive the transformation from chronic inflammation to malignancy.

Second-hand (para-occupational) exposure is a real and documented cause of mesothelioma. Family members of workers — particularly spouses who washed asbestos-contaminated work clothing — have developed mesothelioma decades later. Children who played around a parent's work clothes are also at elevated risk. No safe level of asbestos exposure has been established for mesothelioma.

High-risk occupations include: shipbuilding and ship repair (the highest historical risk group; ships were heavily insulated with asbestos), construction and building trades (insulation installers, pipe fitters, electricians, carpenters), automotive mechanics (brake pad replacement), asbestos mining and milling, boiler workers, railroad workers, and military veterans (especially Navy personnel who served aboard ships built before 1980).

Asbestos remains legal in the United States for certain limited uses — the EPA's proposed ban in 2024 marked the first comprehensive federal action in decades, though it faced legal challenges. More than 60 other countries have imposed outright bans. This ongoing limited use, combined with existing asbestos still present in older buildings, means new exposures continue to occur.

One important non-asbestos cause deserves mention: erionite, a naturally occurring volcanic zeolite fiber found in certain regions of Turkey (particularly Cappadocia) and some areas of the western United States. Erionite has a fiber shape similar to amphibole asbestos and causes mesothelioma at rates far exceeding typical asbestos exposure — it accounts for mesothelioma clusters in some Turkish villages where it outcrops in building stone. This demonstrates that it is the fiber geometry, not asbestos chemistry per se, that drives mesothelioma risk.

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3. Types of Mesothelioma: Pleural, Peritoneal, and Rare Forms

Mesothelioma is classified by the body cavity where it arises. Each type has a distinct presentation, behavior, and treatment approach.

Pleural mesothelioma is by far the most common form, accounting for 75–80% of all mesothelioma cases. It arises from the pleura — the two-layered tissue envelope surrounding the lungs and lining the inner chest wall. As the tumor grows, it typically spreads along the pleural surface rather than forming a single discrete mass, eventually encasing the entire lung in a rind of tumor tissue. The most characteristic early finding is a unilateral (one-sided) pleural effusion — a build-up of fluid in the space between the lung and chest wall. This fluid compresses the lung and causes progressive breathlessness. CT imaging shows irregular pleural thickening, often nodular, frequently involving the mediastinal pleura (the inner wall of the chest between the two lungs). When tumor fully encases the lung, the lung can no longer expand properly — a condition called "trapped lung."

Peritoneal mesothelioma accounts for 15–20% of cases. It arises from the peritoneum — the membrane lining the abdominal cavity and its organs (stomach, intestines, liver, spleen). Peritoneal mesothelioma tends to present with abdominal distension from ascites (fluid in the abdomen), diffuse abdominal pain, weight loss, nausea, and a palpable abdominal mass. Because these symptoms are so nonspecific — they could indicate many different conditions — peritoneal mesothelioma is often diagnosed later than pleural mesothelioma. However, peritoneal mesothelioma has been transformed by a surgical approach (HIPEC — see Treatment section), with median survival now reaching 40 or more months in carefully selected patients, compared to less than 12 months for untreated disease. This represents one of the most dramatic treatment success stories in mesothelioma care.

Pericardial mesothelioma is extremely rare, accounting for less than 1% of cases. It arises from the pericardium — the two-layered sac surrounding the heart. Because the pericardial space is small and the tumor is adjacent to the heart, it can cause pericardial effusion and cardiac tamponade (compression of the heart by fluid, impairing its ability to pump). Prognosis is very poor, partly because surgical options are limited near the heart.

Testicular mesothelioma is the rarest form, arising from the tunica vaginalis, a mesothelial layer surrounding the testes. It may present as a scrotal mass or hydrocele. Its rarity makes evidence-based treatment recommendations difficult.

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4. Histological Subtypes: Epithelioid, Sarcomatoid, Biphasic

Beyond anatomical location, mesothelioma is classified by how its cells look under a microscope — the histological subtype. This classification is critically important because it strongly predicts how the tumor will behave and how well it will respond to treatment.

Epithelioid mesothelioma is the most common subtype (50–60% of cases) and carries the best prognosis. The cells resemble normal mesothelial cells — they are cohesive (stick together), have a relatively uniform appearance, and tend to grow in organized patterns (tubular, papillary, solid). Epithelioid tumors respond better to both chemotherapy and immunotherapy, and patients with this subtype are more likely to be candidates for aggressive surgical treatment. Median survival is 18–24 months with current standard treatments, with meaningful subsets achieving longer survival.

Sarcomatoid mesothelioma accounts for 10–20% of cases and carries the worst prognosis. The cells are spindle-shaped, resembling mesenchymal (connective tissue) cells rather than epithelial cells. This subtype is highly aggressive, less sensitive to chemotherapy, and spreads more rapidly. Median survival is approximately 4–6 months even with treatment. A rare variant, desmoplastic mesothelioma, is a subtype of sarcomatoid that can be particularly difficult to distinguish from benign fibrous tissue, adding diagnostic challenges.

Biphasic (mixed) mesothelioma contains components of both epithelioid and sarcomatoid patterns and accounts for 30–40% of cases. By definition, each component must account for at least 10% of the tumor. Prognosis is intermediate, but heavily influenced by the ratio of the two components: a tumor that is 80% epithelioid and 20% sarcomatoid behaves closer to pure epithelioid, while the reverse carries a prognosis approaching sarcomatoid.

Pathologists use immunohistochemistry (IHC) — staining tumor samples with antibodies to specific proteins — both to confirm the diagnosis of mesothelioma and to distinguish it from other cancers, particularly lung adenocarcinoma, which can look similar. Mesothelioma characteristically stains positive for calretinin, WT-1 (Wilms' tumor 1 protein), D2-40 (podoplanin), and CK5/6 (cytokeratin 5/6), and negative for CEA (carcinoembryonic antigen), TTF-1 (thyroid transcription factor-1), and Ber-EP4 — markers that are positive in lung adenocarcinoma. Getting the panel right is essential, because misdiagnosis leads to wrong treatment.

More recently, BAP1 (BRCA1-associated protein 1) loss by IHC has emerged as a highly specific marker of malignant mesothelioma versus reactive mesothelial hyperplasia (benign inflammation that can mimic mesothelioma). Germline BAP1 mutations also define a hereditary mesothelioma syndrome in which family members face elevated lifetime risk.

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5. Symptoms: Late Presentation and Why It Matters

One of the most clinically important facts about mesothelioma is that its symptoms are vague, gradual, and easily attributed to more common and less serious conditions. This means that by the time most patients seek care, the disease is already at an advanced stage. The median time from first symptom to diagnosis is 3 to 6 months — and most patients are found to have Stage III or IV disease at the time of diagnosis.

Pleural mesothelioma symptoms typically develop insidiously:

Peritoneal mesothelioma symptoms are predominantly abdominal:

For any patient with a significant history of asbestos exposure, these symptoms should prompt immediate evaluation specifically for mesothelioma, not just generic workup for "common" explanations. Telling a pulmonologist or primary care physician explicitly about asbestos exposure history is critical — many physicians, especially younger ones, may not reflexively connect chest symptoms to occupational asbestos exposure.

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6. Diagnosis: Biopsy, Imaging, Biomarkers

Diagnosing mesothelioma requires tissue — a biopsy is essential. Imaging provides the roadmap, and biomarkers offer supplementary information, but no blood test or scan alone can definitively diagnose mesothelioma.

Imaging

CT scan of the chest and abdomen is the standard first imaging study. In pleural mesothelioma, CT typically shows unilateral pleural thickening (often more than 1 cm), which may be nodular, irregular, or circumferential (wrapping around the lung). Involvement of the mediastinal pleura — the pleural surface between the two lungs — is highly characteristic. A pleural effusion is almost always present in early disease. As tumor progresses, CT shows encasement of the lung, invasion of the chest wall, diaphragm, or mediastinum, and lymph node enlargement.

PET-CT (positron emission tomography) adds metabolic information to anatomical detail. Mesothelioma cells are metabolically active and take up the tracer (fluorodeoxyglucose, FDG) avidly. PET-CT is used primarily for staging — identifying lymph node involvement and distant spread — and for treatment planning.

MRI provides superior soft-tissue contrast compared to CT and is particularly valuable for assessing chest wall invasion, diaphragm involvement, and proximity to major vessels — information critical for surgical planning. MRI is superior to CT for determining whether a tumor is resectable.

Biopsy

CT-guided core needle biopsy of the pleural thickening is typically the first biopsy approach. It is minimally invasive, performed under local anesthetic, and achieves a definitive diagnosis in 80–90% of cases when adequate core tissue is obtained. However, if the pleural thickening is diffuse or the CT-guided biopsy is non-diagnostic (which happens, especially in sarcomatoid mesothelioma), a more invasive approach is needed.

Thoracoscopy / VATS (video-assisted thoracoscopic surgery) is the gold-standard biopsy approach when CT-guided biopsy fails or when additional procedures are planned simultaneously. A camera and instruments inserted through small chest incisions allow direct visualization of the pleura, targeted biopsy of visually abnormal areas, and often pleurodesis (obliterating the pleural space to prevent fluid re-accumulation) at the same operation. Larger tissue samples improve diagnostic accuracy, particularly for determining histological subtype.

Cytology of pleural fluid (examining cells shed into the effusion) has low sensitivity — only about 32% of mesothelioma effusions contain enough diagnostic malignant cells to make the diagnosis. A negative pleural fluid cytology does not rule out mesothelioma. Biopsy is always required.

Biomarkers

Serum mesothelin (MESOMARK assay) — mesothelin is a cell-surface glycoprotein overexpressed by mesothelioma cells, particularly the epithelioid subtype. Serum levels are elevated in approximately 50% of mesothelioma patients. It is not sensitive enough for screening but is useful for monitoring treatment response and disease progression. Mesothelin is also elevated in some ovarian, pancreatic, and lung cancers, so it is not specific.

Fibulin-3 — a glycoprotein elevated in plasma and pleural fluid of mesothelioma patients; under investigation as a diagnostic and prognostic biomarker but not yet standard clinical practice.

HMGB1 (high-mobility group box protein 1) — a nuclear protein released during cell damage; elevated in both mesothelioma patients and people with asbestos exposure who have not yet developed cancer, raising interest as an early detection biomarker. Not yet in routine clinical use.

Genetic analysis of tumor tissue, including testing for BAP1 loss, CDKN2A deletion (by FISH — fluorescence in situ hybridization), and other mutations, increasingly informs diagnosis (especially distinguishing malignant from reactive mesothelial proliferations) and may in the future guide selection of targeted therapies.

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7. Staging and Prognosis

Mesothelioma staging follows the TNM system (Tumor, Nodes, Metastasis) as defined by the International Association for the Study of Lung Cancer (IASLC) and endorsed in the 8th Edition of the TNM Classification. Staging applies primarily to pleural mesothelioma; peritoneal mesothelioma uses a different peritoneal cancer index system.

Stage I: Tumor confined to the ipsilateral (same-side) pleura — either the visceral pleura (covering the lung surface), the parietal pleura (lining the chest wall), or both, but without involvement of lymph nodes or distant sites. Stage I disease is potentially resectable. Median survival approximately 22 months with optimal treatment.

Stage II: Tumor has spread to involve the ipsilateral lung, diaphragm, or pericardium, or has spread to involve the mediastinal pleura (the pleura between the two lung spaces). Still potentially resectable in selected patients. Median survival approximately 17 months.

Stage III: Locally advanced disease. Tumor involves the chest wall, mediastinal structures (heart, trachea, esophagus), or the endothoracic fascia, or there is involvement of ipsilateral mediastinal lymph nodes (N1) or subcarinal/contralateral nodes (N2). Stage III disease is generally unresectable. Median survival approximately 16 months.

Stage IV: Distant metastatic disease. This includes spread to the opposite pleura, peritoneum, or other distant organs (M1), or involvement of contralateral mediastinal or supraclavicular lymph nodes (N3). Stage IV is uniformly unresectable. Median survival approximately 12 months.

Beyond stage, several factors strongly influence individual prognosis:

Overall, mesothelioma carries a poor prognosis, but outcomes have improved meaningfully with modern immunotherapy combinations. Long-term survivors (beyond 5 years) exist, particularly among younger patients with Stage I–II epithelioid disease who undergo multimodal treatment at specialized centers.

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8. Treatment: Surgery, Chemotherapy, Immunotherapy

Mesothelioma treatment is complex and depends heavily on disease extent (stage), histological subtype, patient fitness (performance status), and the specific type (pleural vs. peritoneal). Treatment is best managed at specialized mesothelioma centers with multidisciplinary teams including thoracic surgeons, medical oncologists, radiation oncologists, and palliative care specialists.

Surgery (Pleural Mesothelioma)

Surgery is an option only for a minority of patients — those with Stage I–II epithelioid disease and excellent performance status. Two main surgical procedures are used:

Extrapleural pneumonectomy (EPP) is the most radical operation: removal of the entire affected lung along with the adjacent pleura, ipsilateral diaphragm, and ipsilateral pericardium as an en-bloc resection. The intention is complete macroscopic removal of all visible tumor. EPP was historically the preferred aggressive surgical option, but it carries significant operative mortality (4–7% in experienced centers) and major morbidity. The MARS feasibility trial (2011) raised important questions about whether EPP actually prolonged survival compared to no EPP, and enthusiasm for EPP has diminished. It remains an option at specialized centers for carefully selected patients.

Pleurectomy/Decortication (P/D) removes the involved pleura but spares the underlying lung. It results in lower operative mortality and faster recovery than EPP and has become increasingly preferred at most centers. Extended P/D also resects the diaphragm and pericardium when involved. The MARS-2 trial is prospectively comparing (extended) P/D versus no surgery in combination with chemotherapy and immunotherapy; results will further clarify the role of surgery. Surgery is almost always combined with chemotherapy and sometimes radiation as part of a multimodal approach.

First-Line Chemotherapy

The chemotherapy backbone for mesothelioma was established by the landmark EMPHACIS trial (2003): cisplatin plus pemetrexed is the standard first-line chemotherapy regimen. Pemetrexed is a folate antimetabolite that inhibits multiple folate-dependent enzymes essential for DNA synthesis. In the EMPHACIS trial, this combination improved median overall survival from 9.3 months (cisplatin alone) to 12.1 months. An essential practical point: patients receiving pemetrexed must take daily folic acid (400–1000 mcg) and intramuscular vitamin B12 (1000 mcg every 9 weeks) starting 1–2 weeks before the first cycle — without these supplements, pemetrexed causes severe, potentially life-threatening bone marrow suppression and mucositis.

The MAPS trial (2016) added bevacizumab (an anti-VEGF antibody targeting tumor blood vessel growth) to cisplatin-pemetrexed and demonstrated further improvement in overall survival to 18.8 months, though bevacizumab is not universally approved for this indication in all countries and carries additional risks (hypertension, thrombosis, bleeding).

For patients who cannot tolerate cisplatin due to kidney disease or hearing loss, carboplatin is used as a substitute.

Immunotherapy: A Major Advance

The most significant recent advance in mesothelioma treatment has been immunotherapy. In October 2020, the FDA approved the combination of nivolumab plus ipilimumab as first-line treatment for unresectable malignant pleural mesothelioma in adults — the first immunotherapy approval for this disease.

This approval was based on the CheckMate 743 trial (2021): nivolumab (a PD-1 checkpoint inhibitor that releases the brake on T-cell immune attack of tumors) plus ipilimumab (a CTLA-4 inhibitor that provides a second complementary immune activation) versus standard cisplatin-pemetrexed chemotherapy. Results were striking: median overall survival was 18.1 months with immunotherapy versus 14.1 months with chemotherapy; 2-year overall survival was 41% versus 27%. Importantly, the benefit was particularly pronounced in patients with non-epithelioid (sarcomatoid and biphasic) histology — a group that historically had almost no effective options. The sarcomatoid subgroup showed a median OS of 18.1 months with immunotherapy versus only 8.8 months with chemotherapy.

Second-line chemotherapy options after first-line treatment failure include gemcitabine, vinorelbine, or rechallenge with pemetrexed-based regimens. No second-line option has demonstrated dramatic benefit. Clinical trials offering access to novel agents, including targeted therapies (e.g., for BAP1- or NF2-mutant tumors), antibody-drug conjugates (including mesothelin-targeted agents), and CAR-T cell therapy are actively enrolling and represent the most promising avenue for improving outcomes.

Radiation Therapy

Pleural mesothelioma's diffuse spread along the pleural surface makes definitive radiation therapy challenging — it is impossible to irradiate the entire pleural surface without damaging the underlying lung. Radiation has roles as: (1) prophylactic radiation to procedure tracts (biopsy sites, drain sites, thoracoscopy ports) to prevent tract metastasis — though evidence for routine use is mixed; (2) palliative radiation to painful chest wall metastases; (3) adjuvant radiation after EPP (when the lung has been removed, higher-dose pleural radiation is possible).

Peritoneal Mesothelioma: HIPEC

Peritoneal mesothelioma has its own treatment paradigm. For selected patients with good performance status and limited peritoneal disease, the combination of cytoreductive surgery (CRS) plus HIPEC (Hyperthermic Intraperitoneal Chemotherapy) has transformed outcomes. In CRS-HIPEC, a surgeon removes all visible peritoneal tumor (cytoreduction) and then bathes the entire abdominal cavity with heated chemotherapy (usually cisplatin at 41–43°C) for 60–90 minutes before closing. The heat enhances cisplatin's cytotoxic effect and penetration into residual microscopic tumor. Patients who achieve complete cytoreduction have achieved median survivals of 40–50 months — a remarkable improvement over the less than 12 months seen with systemic chemotherapy alone. This procedure is available only at specialized centers with high surgical volume.

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Mesothelioma is fundamentally an occupational disease with a well-documented, specific cause. This is not a case of unclear causation or multifactorial risk — in a patient with significant occupational or para-occupational asbestos exposure, mesothelioma is a consequence of that exposure. This carries real implications for legal rights and financial compensation.

Taking an Occupational History

A thorough occupational history is essential for every mesothelioma patient — and it is more involved than simply asking "were you exposed to asbestos?" Many patients do not know the specific names of materials they worked with decades ago. Physicians and social workers should ask about every employer from approximately 1950 to 1990, what job tasks were performed, and what materials were present at the worksite. Companies often denied or minimized asbestos use; internal documents from legal cases have repeatedly revealed that manufacturers knew of the hazards decades before workers were warned. Family members of workers should also be asked about laundering work clothes or other household contact with work materials.

Asbestos Trust Funds

Many companies that manufactured or used asbestos products have declared bankruptcy due to the volume of asbestos litigation. As part of their bankruptcy proceedings, they were required to establish asbestos compensation trust funds for present and future victims. As of the mid-2020s, more than 60 such trusts hold an estimated $30+ billion total for current and future claimants. Filing with asbestos trust funds is separate from — and in addition to — any lawsuit.

Personal Injury Lawsuits

Mesothelioma patients may be entitled to compensation from companies whose asbestos products caused their disease. A specialized mesothelioma attorney (many work on contingency, meaning no upfront fee) can identify liable companies from the patient's work history and file claims. Statute of limitations — the deadline to file — varies by state, typically ranging from 1 to 6 years from the date of diagnosis (not from the date of exposure). Acting promptly after diagnosis is important.

Veterans' Benefits

U.S. military veterans, particularly Navy veterans who served aboard asbestos-laden ships or worked in shipyards, represent a disproportionately large share of mesothelioma cases. The U.S. Department of Veterans Affairs (VA) recognizes mesothelioma as a service-connected disability for veterans with relevant military history. VA benefits can include disability compensation, free or subsidized treatment at VA medical centers, and dependency and indemnity compensation for surviving spouses.

Reporting and Public Health

Mesothelioma is a reportable occupational cancer under NIOSH (National Institute for Occupational Safety and Health) surveillance programs. Physicians who diagnose mesothelioma can help public health tracking by reporting cases to state cancer registries and NIOSH programs, which inform ongoing regulatory and preventive efforts.

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10. Key Research Papers

  1. Vogelzang NJ, Rusthoven JJ, Symanowski J, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma (EMPHACIS). J Clin Oncol. 2003;21(14):2636–2644. PMID: 12860938. DOI: 10.1200/JCO.2003.11.136
  2. Baas P, Scherpereel A, Nowak AK, et al. First-line nivolumab plus ipilimumab in unresectable malignant pleural mesothelioma (CheckMate 743). Lancet. 2021;397(10272):375–386. PMID: 33485464. DOI: 10.1016/S0140-6736(20)32714-8
  3. Treasure T, Lang-Lazdunski L, Waller D, et al. Extra-pleural pneumonectomy versus no extra-pleural pneumonectomy for patients with malignant pleural mesothelioma: clinical outcomes of the Mesothelioma and Radical Surgery (MARS) randomised feasibility study. Lancet Oncol. 2011;12(8):763–772. PMID: 21723781. DOI: 10.1016/S1470-2045(11)70149-8
  4. Zalcman G, Mazieres J, Margery J, et al. Bevacizumab for newly diagnosed pleural mesothelioma in the Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS). Lancet. 2016;387(10026):1405–1414. PMID: 26719230. DOI: 10.1016/S0140-6736(15)01238-6
  5. Sugarbaker PH, Yan TD, Stuart OA, Yoo D. Comprehensive management of diffuse malignant peritoneal mesothelioma. Eur J Surg Oncol. 2006;32(6):686–691. PMID: 16697564. DOI: 10.1016/j.ejso.2006.02.020
  6. Betta PG, Magnani C, Bensi T, Trincheri NF, Orecchia S. Immunohistochemistry and molecular diagnostics of pleural malignant mesothelioma. Arch Pathol Lab Med. 2012;136(3):253–261. PMID: 22372905. DOI: 10.5858/arpa.2011-0239-RA
  7. Scherpereel A, Astoul P, Baas P, et al. Guidelines of the European Respiratory Society and the European Society of Thoracic Surgeons for the management of malignant pleural mesothelioma. Eur Respir J. 2010;35(3):479–495. PMID: 19717482. DOI: 10.1183/09031936.00063109
  8. Kindler HL, Ismaila N, Armato SG 3rd, et al. Treatment of Malignant Pleural Mesothelioma: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2018;36(13):1343–1373. PMID: 29346042. DOI: 10.1200/JCO.2017.76.6394
  9. van Zandwijk N, Clarke C, Henderson D, et al. Guidelines for the diagnosis and treatment of malignant pleural mesothelioma. J Thorac Dis. 2013;5(6):E254–307. PMID: 24416532. DOI: 10.3978/j.issn.2072-1439.2013.11.28
  10. Robinson BW, Lake RA. Advances in malignant mesothelioma. N Engl J Med. 2005;353(15):1591–1603. PMID: 16221782. DOI: 10.1056/NEJMra050152
  11. Carbone M, Yang H, Pass HI, Bronte V, Doglioni C, Yang H. BAP1 and cancer. Nat Rev Cancer. 2013;13(3):153–159. PMID: 23344544. DOI: 10.1038/nrc3459
  12. Nowak AK, Chansky K, Rice DC, et al. The IASLC Mesothelioma Staging Project: Proposals for Revisions of the T Descriptors in the Forthcoming Eighth Edition of the TNM Classification for Pleural Mesothelioma. J Thorac Oncol. 2016;11(12):2089–2099. PMID: 27727028. DOI: 10.1016/j.jtho.2016.08.147

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