# Pleural mesothelioma

Source: https://onco.cc/cancers/pleural-mesothelioma/  
OnCo record `pleural-mesothelioma` (Cancer). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Pleural mesothelioma grows in the lining of the lung after asbestos exposure and causes breathlessness and chest pain from fluid and thickening. It is rarely curable; the first-line choice is nivolumab with ipilimumab or pembrolizumab with chemotherapy, and surgery to remove the lining is no longer recommended outside trials.

## Summary

Pleural mesothelioma is the commonest form of mesothelioma. It presents with pleural effusion, breathlessness and chest wall pain 20 to 50 years after asbestos exposure, and is diagnosed by thoracoscopic biopsy with immunohistochemistry (calretinin, WT1, D2-40) and loss of BAP1 or MTAP. Epithelioid histology, about two thirds of cases, carries a better outlook than biphasic or sarcomatoid disease. CheckMate 743 made nivolumab plus ipilimumab the first new first-line treatment in 16 years, and KEYNOTE-483 added pembrolizumab with platinum-pemetrexed; both are now standard, with histology guiding the choice. MARS 2 showed that extended pleurectomy and decortication harms rather than helps, so surgery is confined to diagnosis, pleurodesis and trials. Hemithoracic radiotherapy, tumour treating fields and mesothelin-directed therapies are the main lines of research.

## Fields

- Kind: Cancer
- Last checked: 2026-09-16
- Also known as: Malignant pleural mesothelioma; MPM
- Tags: subtype-page
- Group: thoracic
- Burden: About four in five mesotheliomas arise in the pleura; roughly 2,500 cases a year in the UK and 3,000 in the US, almost all decades after asbestos exposure, with incidence still rising in countries that banned asbestos late.
- Subtypes: Epithelioid (about two thirds); Biphasic; Sarcomatoid (including desmoplastic)
- Biomarkers: Histology (epithelioid versus non-epithelioid); BAP1 loss; CDKN2A/MTAP deletion; Mesothelin expression; PD-L1 (not predictive for nivolumab plus ipilimumab)

## Standard of care

- Diagnosis and staging: CT and PET-CT; thoracoscopic biopsy with an immunohistochemistry panel; histology and BAP1/MTAP status recorded because they drive treatment. ([Mesothelioma](https://onco.cc/cancers/mesothelioma/))
- First line, non-epithelioid: Nivolumab plus ipilimumab (CheckMate 743). ([Nivolumab](https://onco.cc/drugs/nivolumab/), [Ipilimumab](https://onco.cc/drugs/ipilimumab/), [CheckMate 743](https://onco.cc/trials/checkmate-743/))
- First line, epithelioid: Pembrolizumab with platinum-pemetrexed (KEYNOTE-483), nivolumab plus ipilimumab, or platinum-pemetrexed with or without bevacizumab, by fitness and preference. ([Pembrolizumab](https://onco.cc/drugs/pembrolizumab/), [Pemetrexed](https://onco.cc/drugs/pemetrexed/), [IND.227 / KEYNOTE-483](https://onco.cc/trials/keynote-483/))
- Surgery: Not recommended for cure outside trials after MARS 2; talc pleurodesis or an indwelling pleural catheter controls effusion. ([MARS 2](https://onco.cc/trials/mars-2/))
- Second line: Nivolumab (CONFIRM) if not given first line; chemotherapy rechallenge or gemcitabine or vinorelbine after immunotherapy. ([Nivolumab](https://onco.cc/drugs/nivolumab/))

## State of the art

- Immunotherapy doubled the share of patients alive at five years compared with chemotherapy alone, but most patients still die of the disease within two years.
- Randomised evidence has removed radical surgery from standard care, sparing patients a major operation with no benefit.
- Mesothelin is expressed on almost every tumour cell, and the next generation of antibody-drug conjugates and CAR-T cells is built on it.

## Open problems

- No curative treatment for the majority; median survival with the best regimens is about 18 months.
- Sarcomatoid disease responds poorly to everything except immunotherapy.
- No screening test for exposed workers, though BAP1 germline carriers and asbestos cohorts are being followed.

## Sources

- Wikipedia: https://en.wikipedia.org/wiki/Mesothelioma
- Wikipedia: https://en.wikipedia.org/wiki/Mesothelioma
- Mesothelioma UK: https://www.mesothelioma.uk.com/

## Connected records

- drugs: [Ipilimumab](https://onco.cc/drugs/ipilimumab/), [Nivolumab](https://onco.cc/drugs/nivolumab/), [Pembrolizumab](https://onco.cc/drugs/pembrolizumab/), [Pemetrexed](https://onco.cc/drugs/pemetrexed/)
- trials: [CheckMate 743](https://onco.cc/trials/checkmate-743/), [IND.227 / KEYNOTE-483](https://onco.cc/trials/keynote-483/), [MARS 2](https://onco.cc/trials/mars-2/)
- ideas: [Antibody-drug conjugates for mesothelioma: why they have failed so far and how they could work](https://onco.cc/ideas/idea-adc-for-mesothelioma/)
- cancers: [Mesothelioma](https://onco.cc/cancers/mesothelioma/)

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