Mesothelioma is extremely rare in children and adolescents, with only 2% to 5% of patients presenting during the first two decades of life. Fewer than 300 cases in children have been reported. Mesothelioma may present in the thoracic/pleural region or in the peritoneum, and the two presentations have different clinical courses and prognoses. In adults, these tumors have been associated with exposure to asbestos, exposure to radiation, and inherited mutations of the BAP1 gene. These risk factors are rare in pediatric patients.[3,4,5,6]
Mesothelioma may develop after successful treatment of an earlier cancer, especially after treatment with radiation therapy.[3,7,8] The amount of radiation exposure required to develop cancer is unknown. There is no information about the risk in children who are exposed to asbestos.
This tumor can involve the membranous coverings of the lung, the heart, or the abdominal organs.[9,10,11]; [Level of evidence: 3iiA] These tumors can spread over the surface of organs, without invading far into the underlying tissue, and may spread to regional or distant lymph nodes.
Biologically, malignant mesothelioma occurring in children, adolescents, and young adults differs from its adult counterpart because there is no relationship to asbestos exposure. Recurrent ALK gene fusions have been described in children and adolescents with mesothelioma, and they more commonly occur in female patients with peritoneal primary tumors. ALK gene fusions involve various partners, including STRN, TPM1, and EML4.
Diagnostic thoracoscopy should be considered in suspicious cases to confirm diagnosis. Cross-sectional imaging may suggest the diagnosis of peritoneal mesothelioma, but diagnostic biopsy by laparoscopy or open laparotomy is required.
Cancer in children and adolescents is rare, although the overall incidence has been slowly increasing since 1975. Referral to medical centers with multidisciplinary teams of cancer specialists experienced in treating cancers that occur in childhood and adolescence should be considered. This multidisciplinary team approach incorporates the skills of the following health care professionals and others to ensure that children receive treatment, supportive care, and rehabilitation that will achieve optimal survival and quality of life:
(Refer to the PDQ Supportive and Palliative Care summaries for specific information about supportive care for children and adolescents with cancer.)
The American Academy of Pediatrics has outlined guidelines for pediatric cancer centers and their role in the treatment of pediatric patients with cancer. At these pediatric cancer centers, clinical trials are available for most types of cancer that occur in children and adolescents, and the opportunity to participate is offered to most patients and their families. Clinical trials for children and adolescents diagnosed with cancer are generally designed to compare potentially better therapy with current standard therapy. Most of the progress made in identifying curative therapy for childhood cancers has been achieved through clinical trials. Information about ongoing clinical trials is available from the NCI website.
Dramatic improvements in survival have been achieved for children and adolescents with cancer. Between 1975 and 2010, childhood cancer mortality decreased by more than 50%. Childhood and adolescent cancer survivors require close monitoring because side effects of cancer therapy may persist or develop months or years after treatment. (Refer to the PDQ summary on Late Effects of Treatment for Childhood Cancer for specific information about the incidence, type, and monitoring of late effects in childhood and adolescent cancer survivors.)
Childhood cancer is a rare disease, with about 15,000 cases diagnosed annually in the United States in individuals younger than 20 years. The U.S. Rare Diseases Act of 2002 defines a rare disease as one that affects populations smaller than 200,000 people. Therefore, all pediatric cancers are considered rare.
The designation of a rare tumor is not uniform among pediatric and adult groups. In adults, rare cancers are defined as those with an annual incidence of fewer than six cases per 100,000 people. They account for up to 24% of all cancers diagnosed in the European Union and about 20% of all cancers diagnosed in the United States.[5,6] Also, the designation of a pediatric rare tumor is not uniform among international groups, as follows:
Most cancers in subgroup XI are either melanomas or thyroid cancer, with other types accounting for only 1.3% of cancers in children aged 0 to 14 years and 5.3% of cancers in adolescents aged 15 to 19 years.
These rare cancers are extremely challenging to study because of the low number of patients with any individual diagnosis, the predominance of rare cancers in the adolescent population, and the lack of clinical trials for adolescents with rare cancers.
Information about these tumors may also be found in sources relevant to adults with cancer, such as the PDQ summary on Malignant Mesothelioma Treatment (Adult).
Treatment options for childhood malignant mesothelioma include the following:
The treatment of patients with malignant pleural mesothelioma is controversial. Outcomes for patients are poor despite treatment with radical surgical resection, chemotherapy, and radiation therapy. Treatment with newer agents and immunotherapy is under investigation.
Radical surgical resection has been attempted with mixed results. In adults, multimodal therapy that includes extrapleural pneumonectomy and radiation therapy after combination chemotherapy with pemetrexed-cisplatin may achieve durable responses.[Level of evidence: 2A] However, this approach remains highly controversial.
Hyperthermic intrapleural chemotherapy, in conjunction with radical surgical resection, has been used to treat adults with pleural mesothelioma. Although results have been encouraging, hyperthermic intrapleural chemotherapy has not been validated in controlled clinical trials because of the rarity of the tumor.[1,5,6] A single-institution experience reported on seven children with intraperitoneal mesothelioma who were treated with surgery and HIPEC. At last available follow-up, five of the seven patients were alive with minimal or no evaluable disease.
The European Cooperative Study Group on Pediatric Rare Tumors retrospectively reviewed children, adolescents, and young adults (aged ≤21 years) diagnosed with mesothelial tumors and treated between 1987 and 2018. Investigators identified 15 male patients and 18 female patients. Only one patient had documented exposure to asbestos. The primary tumor was mainly in the peritoneum (23 patients). The histology was either multicystic mesothelioma of the peritoneum (6 patients) or malignant mesothelioma (27 patients). The response rate to treatment with cisplatin-pemetrexed was 50% (6 of 12 cases). After a median follow-up of 6.7 years (range, 0–20 years), the 5-year overall survival rate was 82.3%, and the event-free survival rate was 45.1%. All patients with multicystic mesothelioma were alive after surgery (5 patients) and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (1 patient).
In one case report, a patient aged 13 years with a peritoneal mesothelioma and a STRN-ALK fusion responded to ceritinib treatment.
Pain is an infrequent symptom. However, if it occurs, radiation therapy may be used for palliation.
Refer to the PDQ summary on Malignant Mesothelioma Treatment (Adult) for more information.
Information about National Cancer Institute (NCI)–supported clinical trials can be found on the NCI website. For information about clinical trials sponsored by other organizations, refer to the ClinicalTrials.gov website.
The following is an example of a national and/or institutional clinical trial that is currently being conducted:
Patients with tumors that have molecular variants addressed by treatment arms included in the trial will be offered treatment on Pediatric MATCH. Additional information can be obtained on the NCI website and ClinicalTrials.gov website.
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Editorial changes were made to this summary.
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Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of childhood mesothelioma. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Pediatric Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewers for Childhood Mesothelioma Treatment are:
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Levels of Evidence
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The preferred citation for this PDQ summary is:
PDQ® Pediatric Treatment Editorial Board. PDQ Childhood Mesothelioma Treatment. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/types/mesothelioma/hp/child-mesothelioma-treatment-pdq. Accessed <MM/DD/YYYY>.
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Last Revised: 2022-02-25
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