Mesothelioma treatment typically involves a multimodal approach combining surgery, chemotherapy, immunotherapy, and/or radiation therapy. The specific treatment plan depends on the type of mesothelioma, stage at diagnosis, cell type, and the patient's overall health. In 2020, the FDA approved the immunotherapy combination of nivolumab (Opdivo) and ipilimumab (Yervoy) — the first new treatment approved for mesothelioma in 16 years.
Surgery
Pleurectomy/Decortication (P/D): Removes the diseased pleura and visible tumor while preserving the lung. This is increasingly the preferred surgical approach because it maintains lung function and has lower surgical risk than more aggressive options. Best suited for Stage I–II patients with epithelioid cell type.
Extrapleural Pneumonectomy (EPP): Removes the entire affected lung along with the pleura, diaphragm, and pericardium. A more aggressive surgery used in select cases where complete tumor removal requires lung sacrifice. Recovery is longer and more demanding than P/D.
HIPEC (Hyperthermic Intraperitoneal Chemotherapy): For peritoneal mesothelioma, cytoreductive surgery removes all visible tumor from the abdomen, followed by heated chemotherapy applied directly to the abdominal cavity. HIPEC has transformed peritoneal mesothelioma outcomes, with 5-year survival rates reaching 50–60% in select patients.
Chemotherapy
The standard first-line chemotherapy regimen is pemetrexed (Alimta) combined with cisplatin. For patients who cannot tolerate cisplatin, carboplatin is used as an alternative. Chemotherapy is typically administered in 4 to 6 cycles, with each cycle lasting approximately 21 days. Approximately 40–50% of patients show tumor response to first-line chemotherapy.
Immunotherapy
The FDA-approved immunotherapy regimen of nivolumab (Opdivo) + ipilimumab (Yervoy) represents the most significant treatment advance for mesothelioma in over a decade. Approved on October 2, 2020, based on the CheckMate 743 clinical trial, this combination achieved a median survival of 18.1 months compared to 14.1 months with chemotherapy alone. Immunotherapy works by helping the patient's own immune system recognize and attack cancer cells.
Radiation Therapy
Radiation is typically used as an adjuvant treatment (after surgery) to target remaining cancer cells, or as palliative treatment to reduce pain and manage symptoms. External beam radiation therapy (EBRT) and intensity-modulated radiation therapy (IMRT) are the most common techniques. Radiation is rarely curative on its own for mesothelioma but plays an important role in multimodal treatment plans.
Clinical Trials
Clinical trials provide access to emerging treatments not yet widely available. Current areas of active mesothelioma research include new immunotherapy combinations, gene therapy, tumor-treating fields (TTFields/Optune), photodynamic therapy, targeted therapy, and CAR-T cell therapy. Clinical trials are free to participants, available regardless of insurance status, and are especially important for Stage III–IV patients where standard treatment options are more limited.
Multimodal Treatment
The most effective mesothelioma treatment plans combine two or more approaches. Common combinations include surgery + chemotherapy + radiation, surgery + HIPEC (for peritoneal mesothelioma), and chemotherapy + immunotherapy. Treatment decisions should be made at specialized mesothelioma treatment centers where oncologists have experience with this rare cancer and access to the latest clinical trials.