Traitements du mésothéliome pleural malin : le point en 2009

Malignant pleural mesothelioma (MPM) remains a rare tumour related to occupational asbestos exposure. The incidence of MPM is increasing with, currently, 800 to 1,000 new cases each year in France. The molecular carcinogenesis of MPM is still poorly understood but gene alterations of NF2, c-met, WT1 RASSF1A, and p16, that control cell division and apoptosis, have been described and could be targeted for future biotherapies. Current therapeutic strategy still includes irradiation of drainage channels or pleural punctures with 3 × 7 Gy in the four weeks following those procedures. Rarely, in carefully selected patients, extra-pleural pneumonectomy (EPP) can be performed. The recommended first-line chemotherapy is based on a doublet of pemetrexed (or ralitrexed) and cisplatin, the only regime that has demonstrated, in a phase 3 setting, global increase in survival and improvement in quality of life when compared to cisplatin-based monotherapy. Multimodal therapeutic strategy in carefully selected patients with neo-adjuvant chemotherapy, radical surgery (EPP) and post-operative hemi-thoracic radiotherapy has resulted in somewhat disappointing results. Anti-angiogenic agents as bevacizumab could be of interest but remain to be tested in on-going, randomized, phase 3 trials. Serum markers such as mesothelin (SRMP) need to be evaluated prospectively for prediction of response to chemotherapy, since standard CT-scan evaluation is often uncertain. Similarly, PETCT also deserves further prospective evaluation.