Control of pleural effusion
The fluid can be removed with a needle (aspirated) drained with a tube ( intercostal drain) or thespace obliterated by removing the fluid, then inserting a sclerosant ( sterile talc) into the space to stick the 2 layers of pleura together. This procedure is called pleurodesis and can be done under local or general anaesthetic.]
Drug Treatment
Under review
Role of Surgery
Decortication
This is an operation to remove the bulk of the tumour, leaving the lung intact. Its primary aim is to get rid of the fluid and thereby relieve the symptoms of breathlessness and possibly pain. It usually requires a cutting operation between the ribs, then the diseased pleura is stripped off the inner chest wall and lung. The main principle is to get into the layer between the diseased and normal tissue, in a similar way to removing the peel from an orange. Some pleura cannot be removed safely in this manner and is left behind: the operation should not be regarded as potentially curative.
Pleuropneumonectomy
Only the fittest patient with the most favourable type of disease (epithelioid) can be considered for this type of surgery. It is only done in a few centres in the UK. The first major series of this type of operations were done in Shotley Bridge hospital near Durham in the 1970’s and lead to one of the staging systems that are used to assess extent of disease. It was associated with a high risk of death post operatively (30%) but the technique has been refined and the death rate is more in the range of 5-10%.
The patient is fully investigated with CT and MRI scans as mentioned and other tests are done to assess fitness for surgery in particular looking at the heart reserve and how strong the remaining lung might be. Most patients will get a small preliminary operation of biopsy (see Biopsy and pleurodesis above); and even a second small procedure called mediastinoscopy to check that glands behind the breastbone are not involved. The latter again is done through a small incision and can be done as a day case.
If all these tests are satisfactory the operation of pleuropneumonectomy can go ahead. Again, there is a cutting operation between the ribs (a thoracotomy), but this time the lung and the chest wall lining are removed as a single block. Included in the block is about half of the bag that surrounds the heart (the pericardium) and the breathing muscle between the chest and the abdomen –the diaphragm. Special plastic sheeting is used to reconstruct these two areas.
Pleuropneumonectomy is an extensive operation, whose intent is to cure the patient of their tumour. It takes an experienced operator 4-5 hours to perform. In addition there are complications to watch out for in the postoperative period such as breathing failure and infection. In an uncomplicated patient a hospital stay of about 7 days would be the average. The best results with this operation have been reported from Boston, USA. Under very favourable circumstances, 2 out of every 5 patients undergoing this surgery can still be alive at 5 years. These patients in the series had other forms of treatment too such as chemotherapy and radiotherapy-operation alone is probably not worthwhile
The only curative treatment is removal of the affected pleura and underlying lung (radical pleura – pneumonectomy) often followed by radiotherapy and chemotherapy. This aggressive approach is only suitable when people are fit enough and with limited enough disease.
Radiotherapy
Radiotherapy is used in 2 contexts. After pleural fluid has been aspirated it is common for the tumour to track up the needle track and produce a hard lump under the skin. If the area of previous aspirations is eradicated within 4 weeks, the development of such a lump can be prevented. The other role of radiotherapy is for palliation of symptoms such a pain.
Control of fluid (Pleural Effusion)
Symptom Control ( Palliative Care)
The pleura are richly supplied with pain nerve endings and pain is a common symptom. It often requires a combination of different pain killers. Other interventions sometimes include TENS (transcutaneous electric nerve stimulation) or nerve block.
New Approaches
Cordotomy
Cordotomy can help patients whose tumour is so serious that strong pain-killing drugs, such as morphine, are poorly effective.
A small number of pain clinicians nationwide are trained to perform the procedure, which involves interrupting the nerves that transmit pain from one side of the patient’s body at the side of the neck.
Palliative care is about maximising the quantity of quality life for the patient. A cordotomy can relieve suffering and improve the quality of life for mesothelioma patients for a period of up to two years.
The mesothelioma tumour tends to develop in the lining of either the chest wall and lungs or the abdomen. It is in the more complex cases, where the tumour causes severe and uncontrollable pain on one side of the body, that a cordotomy can help.
The procedure involves inserting a small needle (about the size of a blood-test needle) into the spinal cord at the side of the neck under the angle of the jaw. It is placed precisely with the aid of x-ray imaging.
Once in place, a series of stringent tests are carried out during the procedure to safeguard the patient and further check the needle’s exact position. The end of the needle is then carefully heated to a temperature of 70 to 80C, twice for about 30 to 40 seconds. This stops the pain nerves functioning below the neck on the opposite side of the body from where the needle is placed.
Studies have shown cordotomy to be successful in 90 per cent of cases. The vast majority of these patients have been able to downgrade to a much lower dose of painkillers, with fewer side effects. Other patients have been able to stop taking them altogether.
Sometimes the procedure can be unsuccessful because the pain nerves cannot be identified safely. Any risk should be discussed with the doctor.
There are currently four centres offering a Percutaneous Cordotomy service to patients – these cover the South, North, North-West and Midlands. They have all agreed to have their details circulated.
Drs Derek Pounder, Mike Williams or Nick Campkin, The Pain Clinic, St Mary’s Hospital, Milton Road, Portsmouth PO3 6AD
Tel: 02392 286000 ext. 2536 Fax: 02392 866388
Dr Paul Cook (Consultant in Palliative Care & Anaesthesia), Room 21, Central Offices, Pennine Square, Royal Oldham Hospital, Rochdale Road, Oldham, OL1 2JH
Tel: 0161 656 1912 Fax: 0161 656 1929 E-mail: paul.cook@pat.nhs.uk
Dr Hugh Antrobus, Pain Clinic, Warwick Hospital, Warwick, CB34 5BW
Tel: 01926 495321 ext. 4738 Fax: 01926 482613 E-mail: hugh.antrobus@swh.nhs.uk
Dr Mahohar Sharma, Consultant in Pain Management, The Walton Centre for Neurology and Neurosurgery NHS Trust, Lower Lane, Liverpool, L9 7LJ
Tel: 0151 5298294 (Pain Clinic) or 0151 5292098 (Aintree Palliative Care Service)
Cryoablation
Management of mesothelioma has been among the most challenging of cancer therapy. Most decisive factor in survival remains stage at diagnosis and type of mesothelioma, with epitheloid type having better survival compared to sarcomatous type. Chemotherapy has shown little success in increasing survival.
Although not curative, best results to improve survival comes from patients surviving surgery namely pleurectomy (decortication) or extrapleural pneumonectomy, in combination with chemotherapy and radiotherapy. Both the surgical procedures are associated with morbidity and mortality and require expertise such that only few surgeons have the stamina or dare take on these operations. Almost all patients who undergo surgery have recurrence at some point in their disease course.
Cryoablation is an alternative minimally invasive procedure used in adjunct with standard therapies described. Cryoablation uses principles of cold temperature dissipation to induce thermal injury in target tissues.
The applicators allow conduction of compressed argon gas in applicators interior hollow chambers (large needle approximately 2 mm in diameter) which in turn lead to subzero temperatures in the applicator and surrounding tissue [1], forming an ice ball (cryo zone) which will kill any cells it engulfs. Currently the maximum size of iceball attained remains at 4 cm, which limits ablating large tumors.
Although multiple applicators can be used to reach larger ice balls (with the maximum ice ball obtained by my team being 9 cm), it does come with increased risk of morbidity [2].
Currently there is handful of centers with enough expertise to use cryoablation in management of mesothelioma. The principal indications to improve survival include ablation of localized invasive tumor to make the patient eligible for surgery and ablation of tumor following recurrence. As mentioned previously almost all patients have localized recurrences and are ineligible for repeat surgery. Cryoablation can be performed on multiple lesions at a time.
Infrequently, I have ablated up to four lesions in a single ablation setting. Another set of indications for cryoablation is palliative control of pain. These tumors invade the chest wall and the ribs and can cause neurogenic and osseous pain.
Even though the survival may not increase, most of my patients have had improved quality of life after cryoablation. I have found cryoablation a safe and relatively quick method to control pain.
Finally, cryoablation has been used for focal control of tumor invading into vital organs like heart to improve quality of life or even survival. Like all procedures there are some risks involved particularly hemorrhage and damage to vital structures, which needs to be considered while selecting patients.
Mesothelioma management requires multidisciplinary, strong and individualized approach to control the tumor early in the course to improve survival or quality of life.
1. Hoffman, NE, Bischof, JC. The Cryobiology of cryosurgical injury. Urol 2002; 60(supple 2a):40-49.
2. Fereidoun Abtin MD, Carol Wu MD, Ali Golshan MD, Robert Suh MD. CT guided percutaneous cryoablation of thoracic tumors: technical feasibility, early efficacy and imaging of 27 treated tumors. Scientific session 8, #713, 2nd World congress of Thoracic Imaging and Diagnosis in Chest disease. Valencia May 30-June 2, 2
Fereidoun Abtin MD
Assistant Professor
Department of Radiology, Thoracic Section
David Geffen School of Medicine at UCLA
757 Westwood Plaza, Room 1621
Los Angeles, California 90095-1721
Tel: 310-267-8708
Fax: 310-267-3635
pager: 24918
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Professor Thomas.J.Vogl
Frankfurt am Main
Germany
Tele: 00469 6301 7277
Fax: 004469 6301 7258
Email: T.Vogl@em.un-frankfurt.de
http://www.kgu.de/zard/Diagnostik/index.htm
