Key Takeaways
- The FDA has approved new treatment options for pleural mesothelioma in recent years, offering patients alternatives beyond traditional chemotherapy.
- NovoTTF (Tumor Treating Fields) was FDA-approved in 2019 for pleural mesothelioma. It is a portable device that creates alternating electrical fields in the torso, worn for 18 hours a day, and is designed to disrupt cancer cell division.
- The CheckMate 743 trial showed that combining two immunotherapy drugs — ipilimumab and nivolumab — improved overall survival compared to standard platinum-pemetrexed chemotherapy in previously untreated patients.
- For tumors that can be surgically removed, treatment typically involves four cycles of cisplatin-pemetrexed chemotherapy combined with surgery. Pleurectomy decortication and extended pleurectomy decortication have increasingly replaced extrapleural pneumonectomy.
- Radiation therapy can be used before surgery (neoadjuvant), after surgery (adjuvant), or for symptom management (palliative) — depending on the stage and resectability of the tumor.
- Multiple clinical trials are ongoing to better understand how immunotherapy can be used to treat mesothelioma more effectively.
In recent years, the US Food and Drug Administration has approved new therapeutic techniques for new mesothelioma treatments. Malignant pleural mesothelioma has been difficult to treat and the lack of positive results from treatment has made research imperative. Pleural mesothelioma is by far the most common type of mesothelioma, which begins in the lining of the lungs. It affects approximately 75% of all mesothelioma victims.
Diagnosing Mesothelioma
A CT scan is usually used to diagnose pleural mesothelioma and to continue monitoring how the cancer progresses through treatment. Some things that could show up on a CT scan include pleural effusion, pleural plaques, and diffuse pleural thickening.
Normally, the goal of surgery is macroscopic complete resection. Pleurectomy decortication as well as extended pleurectomy decortication have been used in place of extrapleural pneumonectomy in many cases.
Radiation therapy is used to manage pleural mesothelioma and can be used in many ways. It can be administered in adjuvant, neoadjuvant, or palliative settings. If the malignant pleural mesothelioma is resectable, meaning that it can be removed by surgery, radiation therapy is usually administered to the hemithorax either prior to or after non-lung sparing surgery, such as extrapleural pneumonectomy.
When the mesothelioma tumor is resectable, currently, there are usually four cycles of neoadjuvant or adjuvant cisplatin-pemetrexed therapy. There are numerous clinical trials going on that have the goal of helping us understand the benefits of immunotherapy when it comes to treating mesothelioma.
FDA Approval For New Mesothelioma Treatments
When it comes to unresectable disease, or a tumor that cannot be removed through surgical procedure, the previous standard of care in the US was four to six cycles of therapy of platinum-pemetrexed with and without bevacizumab. This was then followed by maintenance therapy. In 2019, the FDA approved NovoTTF for the treatment of pleural mesothelioma. NovoTTF is a portable biomedical device that creates electrical fields in the torso that alternate. For 18 hours a day, mesothelioma patients would keep transducer arrays on their chest. TTFs, or tumor treatment fields are thought to harm cancer cell division.
The CheckMate 743 trial was a trial that compared platinum-pemetrexed to ipilimumab-nivolumab in mesothelioma patients who had not received prior treatment. There was an overall survival benefit in the population that was treated.
In general, there is still a lot more research that needs to be done when it comes to determining the best treatment options for mesothelioma. Treatment can also depend on how progressive the cancer is and the patient’s physical condition. It is promising that the FDA has approved some new treatment modalities.
Frequently Asked Questions
What new treatments have been FDA-approved for mesothelioma?
Two significant developments have occurred in recent years:
- NovoTTF (Tumor Treating Fields) — FDA-approved in 2019, this is a portable biomedical device that creates alternating electrical fields in the torso to disrupt cancer cell division. Patients wear transducer arrays on their chest for 18 hours a day.
- Ipilimumab and nivolumab combination immunotherapy — tested in the CheckMate 743 trial, this combination showed an overall survival benefit compared to standard chemotherapy for previously untreated mesothelioma patients. It became a new standard-of-care option for unresectable pleural mesothelioma.
What is NovoTTF and how does it work?
NovoTTF — short for Novo Tumor Treatment Fields — is a portable device that generates alternating electrical fields targeted at the torso. These fields are thought to interfere with cancer cell division, slowing or stopping tumor growth. Patients wear transducer arrays on their chest for 18 hours a day. It was approved by the FDA in 2019 specifically for the treatment of pleural mesothelioma and can be used alongside other therapies.
What was the CheckMate 743 trial?
CheckMate 743 was a landmark clinical trial that compared two treatment approaches for previously untreated mesothelioma patients: standard platinum-pemetrexed chemotherapy versus a combination of two immunotherapy drugs — ipilimumab and nivolumab. The trial showed that patients receiving the immunotherapy combination had a significant overall survival benefit compared to those on chemotherapy alone, leading to the approval of this combination as a first-line treatment option.
What surgical options are currently used for mesothelioma?
When a mesothelioma tumor is resectable (can be surgically removed), doctors typically aim for macroscopic complete resection — removing all visible tumor. Two main surgical approaches are used:
- Pleurectomy decortication (P/D) — removes the diseased pleural lining while preserving the lung
- Extended pleurectomy decortication (EPD) — a more extensive version that also removes portions of the diaphragm and pericardium
These lung-sparing surgeries have increasingly replaced extrapleural pneumonectomy (EPP), which removes the entire lung. Surgery is typically combined with chemotherapy and/or radiation therapy.
How is radiation therapy used in mesothelioma treatment?
Radiation therapy can be administered in several settings depending on the patient’s treatment plan:
- Neoadjuvant — given before surgery to shrink the tumor
- Adjuvant — given after surgery to target remaining
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