Several staging systems for mesothelioma are used throughout the world. Although the Butchart tumor node metastasis (TNM) and Brigham staging systems are the most commonly used classifications, neither has been widely accepted.

With supportive care, survival of mesothelioma ranges between 4 to 12 months. Attempts to improve survival have been made using a wide variety of therapeutic modalities. Treatment of this tumor using single-modality therapy such as radiotherapy, chemotherapy, or surgery has not demonstrated any improvement in survival.

Two surgical cytoreductive procedures, extrapleural pneumonectomy (EPP) or pleural pneumonectomy and pleurectomy/decortication, have been used in the treatment of MPM. In our experience, EPP is the more effective cytoreductive procedure because decorticating the tumor from the fissures and other recesses during pleurectomy can be difficult. The published results of pleurectomy/decortication in a multimodality setting indicate a median survival between 9 and 21 months and a mortality rate ranging from 1.5% to 5%. Controversy surrounding the use of EPP is based on published trials that report high operative morbidity and mortality with no impact on patient survival when used as a single-modality therapy. With advances in perioperative management and the development of multimodality approaches, long-term survival can, however, be obtained with EPP with perioperative mortality rates of less than 3%.

At the Brigham and Women’s Hospital, a series of 183 patients who underwent trimodality therapy for MPM from 1980 to 1997 was reviewed in 1999. The patients had undergone EPP followed by sequential chemotherapy (carboplatin/paclitaxel) and radiotherapy (55 Gy). Results from this series identified a favorable subgroup of patients who had epithelial histology, tumor-free resection margins, and negative extrapleural lymph nodes. This group of patients had a 46% 5-year survival and a median survival of 51 months. More recently, novel chemotherapeutic approaches have been advocated. Promising new agents are undergoing clinical trial for single modality and adjuvant therapy.