{"markup":"\u003C?xml version=\u00221.0\u0022 encoding=\u0022UTF-8\u0022 ?\u003E\n    \u003Chtml version=\u0022HTML+RDFa+MathML 1.1\u0022\n    xmlns:content=\u0022http:\/\/purl.org\/rss\/1.0\/modules\/content\/\u0022\n    xmlns:dc=\u0022http:\/\/purl.org\/dc\/terms\/\u0022\n    xmlns:foaf=\u0022http:\/\/xmlns.com\/foaf\/0.1\/\u0022\n    xmlns:og=\u0022http:\/\/ogp.me\/ns#\u0022\n    xmlns:rdfs=\u0022http:\/\/www.w3.org\/2000\/01\/rdf-schema#\u0022\n    xmlns:sioc=\u0022http:\/\/rdfs.org\/sioc\/ns#\u0022\n    xmlns:sioct=\u0022http:\/\/rdfs.org\/sioc\/types#\u0022\n    xmlns:skos=\u0022http:\/\/www.w3.org\/2004\/02\/skos\/core#\u0022\n    xmlns:xsd=\u0022http:\/\/www.w3.org\/2001\/XMLSchema#\u0022\n    xmlns:mml=\u0022http:\/\/www.w3.org\/1998\/Math\/MathML\u0022\u003E\n  \u003Chead\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_itu2PgFdrjV-docKmLK8Jn5oXe_05RgvQh73eOhI_mE.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_at_symbol.js?nzl741\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_article_reference_popup.js?nzl741\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_I8yX6RYPZb7AtMcDUA3QKDZqVkvEn35ED11_1i7vVpc.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\n(function(i,s,o,g,r,a,m){i[\u0022GoogleAnalyticsObject\u0022]=r;i[r]=i[r]||function(){(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o),m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m)})(window,document,\u0022script\u0022,\u0022\/\/www.google-analytics.com\/analytics.js\u0022,\u0022ga\u0022);ga(\u0022create\u0022, \u0022UA-15605596-27\u0022, {\u0022cookieDomain\u0022:\u0022auto\u0022});ga(\u0022set\u0022, \u0022page\u0022, location.pathname + location.search + location.hash);ga(\u0022send\u0022, \u0022pageview\u0022);ga(\u0027create\u0027, \u0027UA-189672-26\u0027, \u0027auto\u0027, {\u0027name\u0027: \u0027hwTracker\u0027});\r\nga(\u0027hwTracker.send\u0027, \u0027pageview\u0027);\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\njQuery.extend(Drupal.settings, {\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;15\\\/8\\\/25\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;15\\\/8\\\/25\u0022}],\u0022ac\u0022:{\u0022spmdc;15\\\/8\\\/25\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;15\\\/8\\\/25\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003ENew approaches to malignant pleural mesothelioma are developing through increased knowledge of its genomic landscape that has informed treatment approaches through precision medicine. This session also discussed the roles of surgery and radiotherapy for mesothelioma.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Emalignant pleural mesothelioma\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Egenetics\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Epathology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Esurgery\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Easbestos\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EBAP1 protein\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Etumor markers\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Etreatment outcome\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecombined modality therapy\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eradiation therapy\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eadjuvant\/neoadjuvant therapy\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003EMalignant pleural mesothelioma (MPM) is a disease of increasing concern in the developing world due to asbestos exposure. This session discussed current knowledge of its genomics, the roles of surgery and radiation therapy (RT), and treatment options.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EUnderstanding the Mesothelioma Genome\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EMPM has fewer mutations than other types of lung cancer, explained Giorgio V. Scagliotti, MD, PhD, University of Torino, Torino, Italy. The 3 most common somatic aberrations that occur in MPM are cyclin-dependent kinase inhibitor 2A (about 80% of cases), neurofibromin 2 (\u003Cem\u003ENF2\u003C\/em\u003E; about 60% of cases), and \u003Cem\u003EBRCA1\u003C\/em\u003E-associated protein-1 (\u003Cem\u003EBAP1\u003C\/em\u003E; about 21% of cases, more smokers) [Bott M et al. \u003Cem\u003ENat Genet\u003C\/em\u003E. 2011; Testa JR \u003Cem\u003ENature Genetics\u003C\/em\u003E. 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EThe gene product of \u003Cem\u003ENF2\u003C\/em\u003E is Merlin, which acts as a tumor suppressor gene. When \u003Cem\u003ENF2\u003C\/em\u003E is deleted, the pathway is overactive and its downstream pathway involves a mechanistic target of rapamycin (mTOR). As a result, mTOR inhibitors have been investigated in MPM. As 50% to 60% of mesothelioma has an inactivation of Merlin, inhibiting focal adhesion kinase could have therapeutic potential in Merlin-null tumors, and cell lines have responded to defactinib.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EGene sequencing of MPM has found \u0026gt;\u2005500 mutations in 490 genes, with the vast majority being missense mutations [Guo G et al. \u003Cem\u003ECancer Res\u003C\/em\u003E. 2015]. A frameshift study classified the tumor cell lines into 2 clusters (C1 and C2), with the only significant difference in genetic alterations between these groups in both MPM in culture and MPM tumor samples being related to \u003Cem\u003EBAP1\u003C\/em\u003E (\u003Cem\u003EP\u2005\u003C\/em\u003E\u0026lt;\u2005.04) [de Reyni\u00e8s A et al. \u003Cem\u003EClin Cancer Res.\u003C\/em\u003E 2014]. Variations in \u003Cem\u003EBAP1\u003C\/em\u003E were concentrated mainly in exon 13. The colony stimulating factor 1 receptor gene was found to be more common in MPM than in normal cells [Cioce M et al. \u003Cem\u003ECell Death Dis\u003C\/em\u003E. 2014].\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EAs patients with mutated tumor protein p53 have a worse prognosis than other groups [van Oijen MG, Slootweg PJ. \u003Cem\u003EClin Cancer Res.\u003C\/em\u003E 2000] and \u003Cem\u003EPIK3CA\u003C\/em\u003E mutations correlate with early disease progression, PI3K and mTOR inhibitors have been investigated [Hoda MA et al. \u003Cem\u003EJ Thorac Oncol\u003C\/em\u003E. 2011; Mikami I et al. \u003Cem\u003EOncol Rep.\u003C\/em\u003E 2010; L\u00f3pez-Lago MA et al. \u003Cem\u003EMol Cell Biol.\u003C\/em\u003E 2009].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EThoracic Surgeon\u2019s Evolving Role in MSM\u003C\/h2\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EThe best survival in MSM occurs after multimodality treatment, explained Walter Weder, MD, University Hospital Zurich, Zurich, Switzerland. The main aim of surgery is macroscopic complete resection, through the 2 main procedures of extrapleural pneumonectomy (EPP) and pleurectomy\/decortication (P\/D) [Rice D. \u003Cem\u003EAnn Cardiothorac Surg.\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EA systematic review of EPP vs P\/D found that morbidity data is difficult to compare because the procedures have heterogeneous definitions (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Cao C et al. \u003Cem\u003ELung Cancer.\u003C\/em\u003E 2014]. Perioperative mortality was lower (2.9%) with P\/D than with EPP (6.8%; \u003Cem\u003EP\u003C\/em\u003E\u2005=\u2005.02). Both surgeries should be performed at dedicated MPM centers with experienced staff.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/8\/25\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Meta-analysis of Median Survival and Surgery for MPMSummary of median overall survival outcomes for patients with malignant pleural mesothelioma who underwent extended P\/D or EPP. Circle radius is logistically proportional to the size of individual studies. Solid lines indicate survival measured from the date of diagnosis, and dotted lines indicate survival measured from the date of surgery.EPP, extrapleural pneumonectomy; MPM, malignant pleural mesothelioma; P\/D, pleurectomy\/decortication.Reprinted from Lung Cancer, Vol 83, Cao C et al, A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma, Pages 240-5, Copyright (2013), with permission from Elsevier Ireland Ltd.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-554274296\u0022 data-figure-caption=\u0022\u0026amp;lt;div xmlns=\u0026amp;quot;http:\/\/www.w3.org\/1999\/xhtml\u0026amp;quot;\u0026amp;gt;Meta-analysis of Median Survival and Surgery for MPMSummary of median overall survival outcomes for patients with malignant pleural mesothelioma who underwent extended P\/D or EPP. Circle radius is logistically proportional to the size of individual studies. Solid lines indicate survival measured from the date of diagnosis, and dotted lines indicate survival measured from the date of surgery.EPP, extrapleural pneumonectomy; MPM, malignant pleural mesothelioma; P\/D, pleurectomy\/decortication.Reprinted from \u0026amp;lt;em\u0026amp;gt;Lung Cancer\u0026amp;lt;\/em\u0026amp;gt;, Vol 83, Cao C et al, A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma, Pages 240-5, Copyright (2013), with permission from Elsevier Ireland Ltd.\u0026amp;lt;\/div\u0026amp;gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/8\/25\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/8\/25\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/8\/25\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16316\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003EMeta-analysis of Median Survival and Surgery for MPM\u003C\/p\u003E\n               \u003Cp id=\u0022p-10\u0022\u003ESummary of median overall survival outcomes for patients with malignant pleural mesothelioma who underwent extended P\/D or EPP. Circle radius is logistically proportional to the size of individual studies. Solid lines indicate survival measured from the date of diagnosis, and dotted lines indicate survival measured from the date of surgery.\u003C\/p\u003E\n               \u003Cp id=\u0022p-11\u0022\u003EEPP, extrapleural pneumonectomy; MPM, malignant pleural mesothelioma; P\/D, pleurectomy\/decortication.\u003C\/p\u003E\n               \u003Cp id=\u0022p-12\u0022\u003EReprinted from \u003Cem\u003ELung Cancer\u003C\/em\u003E, Vol 83, Cao C et al, A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma, Pages 240-5, Copyright (2013), with permission from Elsevier Ireland Ltd.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-13\u0022\u003ECurrently, no standardized recommendation exists for surgery type. Preoperative functional assessment is mandatory, including pulmonary function and cardiac assessment. Considerations include performance status, patient desires, extent of tumor load, and adjuvant treatment plans. When macroscopic complete resection is deemed achievable, surgical cytoreduction is indicated [Rusch V et al. \u003Cem\u003EJ Thorac Cardiovasc Surg.\u003C\/em\u003E 2013]. MPM does not respond well to chemotherapy, though induction chemotherapy may allow for downstaging of the tumor and better resectability. However, induction chemotherapy increases surgical mortality and morbidity, and delaying surgery reduces resectability.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EAdjuvant RT has an unclear benefit, though it may reduce local recurrences. Its challenges include the large target volume, nearby vital structures, and adverse events. Palliative RT may be used for pain control.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EThe Role of Radiation Therapy in Mesothelioma\u003C\/h2\u003E\n         \u003Cp id=\u0022p-15\u0022\u003ERT for MPM is used in the palliative setting, in prophylaxis of port-site recurrence, and as an integral part of \u201ccurative\u201d multimodality therapy for resectable disease. However, Umberto Ricardi, MD, University of Turin, Turin, Italy explained that little evidence supports the use of routine RT for MPM. Though RT is used in prophylaxis of port-site recurrence, systematic reviews have concluded that it did not influence the disease course [Chapman E, Garcia Dieguez M. \u003Cem\u003ECochrane Database Syst Rev\u003C\/em\u003E. 2010; Ung YC et al. \u003Cem\u003ERadiother Oncol\u003C\/em\u003E. 2006]. Palliative RT is effective for pain control, as 47% of 30 patients evaluable at week 5 had pain improvement after RT [MacLeod N et al. \u003Cem\u003EJ Thorac Oncol\u003C\/em\u003E. 2015].\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EAdding RT, often combined with chemotherapy, after surgery improved median overall survival (OS) from 10.3 months to 20.1 months in a study of prognostic factors for 945 patients (\u003Cem\u003EP\u003C\/em\u003E\u2005\u0026lt;\u2005.001) [Flores RM et al. \u003Cem\u003EJ Thorac Oncol.\u003C\/em\u003E 2007].\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EThe use of intensity-modulated RT initially produced more fatal pneumonitis than 3D conformal RT. According to Prof Ricardi, if strict constraints are applied, 50 to 54 Gy post-EPP RT is feasible in well-selected patients affected with MPM (low toxicity burden).\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EOpen questions remain on the selection of patients for trimodality treatment. After multimodality therapy for MPM, 75% developed a recurrence (118 of 158 evaluable patients) with a median follow-up of 83 months, 13.1 months to recurrence, and median survival of 15 months [Baldini EH et al. \u003Cem\u003EJ Thorac Cardiovasc Surg.\u003C\/em\u003E 2015], with local relapse in the homolateral hemithorax still representing the most typical pattern of relapse.\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EWhen patients are treated with EPP, it offers complete resection of all gross tumors and allows for the delivery of high-dose adjuvant hemithoracic RT, but it is linked with greater morbidity and mortality than lesser operations. Also, rapid progression of disease and limited life expectancy often occurs. The use of P\/D is diffusively increasing, which often leads to equal or better outcomes than EPP [Hiddinga BI, van Meerbeeck JP. \u003Cem\u003EJ Thorac Oncol\u003C\/em\u003E. 2013].\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EP\/D, as it is a less complete resection than EPP and has a higher risk for locoregional recurrence, poses a difficult problem for delivering RT, noted Prof Ricardi.\u003C\/p\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EAccording to Prof Ricardi, pleural intensity-modulated RT, whether alone or after P\/D, is feasible and safe, with delivered RT doses of 47 to 55 Gy and rates of grade 3 or higher toxicity of 20% to 30%. Adjuvant irradiation after P\/D is not recommended outside clinical trials, which are ongoing.\u003C\/p\u003E\n         \u003Cp id=\u0022p-22\u0022\u003EOverall, MPM still has a dismal prognosis and it is unclear if any local treatment changes long-term survival. No local treatment has been found effective.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-5\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EOld Drugs and New Approaches to Mesothelioma\u003C\/h2\u003E\n         \u003Cp id=\u0022p-23\u0022\u003EMesothelioma was previously considered a rare tumor, is asbestos related, is a public health issue in the developing world, has many diagnostic pitfalls, and has no validated curative treatment, said Paul Baas, MD, PhD, The Netherlands Cancer Institute, Amsterdam, The Netherlands. He explained the problems of mesothelioma studies, including that they take 2 to 8 years, which is too long; the population is heterogeneous in terms of previous treatments, stage and pathology, and measurable disease; the study setup is incomplete and lacks data on the impact of poststudy chemotherapy; and the number of translational studies is limited with no tumor assessments before or after treatment.\u003C\/p\u003E\n         \u003Cp id=\u0022p-24\u0022\u003EFirst-line treatment is chemotherapy, which provides symptom relief and increases OS. The standard is combining cisplatin and anti-folate, and it results in 80% of tumors recurring within 2 years and a median OS of 12 to 13 months, according to a 2003 study.\u003C\/p\u003E\n         \u003Cp id=\u0022p-25\u0022\u003ESo far, novel and targeted agents have had no or very limited success. Amatuximab [Hassan R et al. \u003Cem\u003EClin Cancer Res.\u003C\/em\u003E 2014], thalidomide [Buikhuisen WA et al. \u003Cem\u003ELancet Oncol\u003C\/em\u003E. 2013], and vorinostat [Krug LM et al. \u003Cem\u003ELancet Oncol.\u003C\/em\u003E 2015] have failed or had minimal improvements. The PI3K-mTOR pathway is of interest to target in MPM. One recent study showed that 40% of cases express programmed death ligand [Mansfield AS et al. \u003Cem\u003EJ Thorac Oncol.\u003C\/em\u003E 2014], so immunotherapy is also of interest. Another approach is to test many drugs, including old ones, using a drug library to identify the best approach. The library includes histone deacetylase inhibitors, proteasome inhibitors, anthracyclines, and antineoplastic antibiotics.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/15\/8\/25.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzl741\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzl741\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}