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    Malignant Mesothelioma Treatment (PDQ®): Treatment - Health Professional Information [NCI] - Advanced Malignant Mesothelioma (Stages II, III, and IV)

    Standard treatment options:

    1. Symptomatic treatment to include drainage of effusions, chest tube pleurodesis, or thoracoscopic pleurodesis.[1] (Refer to the PDQ summary on Cardiopulmonary Syndromes for more information.)
    2. Palliative surgical resection in selected patients.[2,3]
    3. For patients with pain related to their cancer, palliative radiation therapy is a consideration.[4,5]
    4. First-line combination chemotherapy with cisplatin and pemetrexed showed improved survival compared with single-agent cisplatin.[6][Level of Evidence: 1iiA]
    5. Multimodality clinical trials.[7,8,9,10]
    6. Intracavitary therapy. Intrapleural or intraperitoneal administration of chemotherapeutic agents (e.g., cisplatin, mitomycin, and cytarabine) has been reported to produce transient reduction in the size of tumor masses and temporary control of effusions in small clinical studies.[11,12,13] Additional studies are needed to define the role of intracavitary therapy.

    Information about ongoing clinical trials is available from the NCI Web site.

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    Many phase II trials of chemotherapy for the treatment of advanced malignant mesothelioma have been reported.[6,14,15] The safety and efficacy of pemetrexed, an antifolate, and cisplatin in chemotherapy-naive patients with malignant mesothelioma who were not eligible for curative surgery was demonstrated in a randomized, phase III trial.[16][Level of evidence: 1iiA] This trial compared pemetrexed (500 mg/m2) and cisplatin (75 mg/m2 on day 1) with cisplatin alone (75 mg/m2 on day 1 intravenously every 21 days). With a total of 456 enrolled patients in the trial, 226 patients received pemetrexed plus cisplatin; 222 patients received cisplatin alone, and 8 patients did not receive therapy. After 117 patients had enrolled, folic acid and vitamin B12 were added to reduce toxic effects. Folic acid (350-1,000 µg orally) was given daily, beginning 1 to 3 weeks before the first chemotherapy dose and continuing daily until 1 to 3 weeks after treatment ended. A vitamin B12 injection (1,000 µg intramuscularly) was administered 1 to 3 weeks before the first chemotherapy dose and was repeated approximately every 9 weeks until treatment ended. Dexamethasone (4 mg) or an equivalent corticosteroid was administered orally twice daily for skin rash prophylaxis to all patients 1 day before, on the day of, and 1 day after each pemetrexed dose.

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