OnCo
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Histology → first-line choice in mesothelioma

Read the tumour type under the microscope first: non-epithelioid tumours should get immunotherapy up front; epithelioid tumours can reasonably get either immunotherapy or chemo-immunotherapy.

In non-epithelioid disease nivolumab-ipilimumab roughly doubled median OS versus chemotherapy (18.1 vs 8.8 months); in epithelioid disease the difference was small (18.7 vs 16.5). Pembrolizumab-chemotherapy showed the same pattern. Guidelines now stratify by histology.

Rationale
Sarcomatoid tumours are chemoresistant but more immune-infiltrated; epithelioid tumours retain chemosensitivity.
Evidence
Pre-specified subgroup analyses of two phase 3 trials plus BEAT-meso.

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