Mesothelioma Treatment Information
Dr Tim Peel
Consultant in general and respiratory medicine and palliative medicine Particular interest is in lung cancer and mesothelioma.
Treatment options include:
Surgery
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.
Chemotherapy
Recent studies have shown that in selected patients (fit ones), chemotherapy can cause the tumour to shrink in size (partial response) and also improve symptoms. There has been no placebo conrolled trials that prove that chemotherapy improves survival. The MSO Trial is currently trying to answer this question.
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)
The pleural effusion associated with mesothelioma caused breathlessness. This can simply be treated by inserting a needle and tapping off up to 2litres of fluid (pleural aspiration). The problem is that the fluid tends to recur (within weeks – days) and the amount of fluid that can be removed is often limited by pain or coughing during the procedure. Amore long lasting solution is to stick up the pleural cavity and thus obliterate the space so that no more fluid can collect – this is called a pleurodesis. It can be performed by a chest physician, who inserts a chest drain under local anaesthetic, or at the Regional cardiothoracic Surgical Centre under general anaesthetic. Both require a spell as an impatient. Success rates vary but tend to be higher with surgical intervention.
Pain Control
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.
Further Surgery Information
Sion Barnard
Thoracic surgeon Newcastle upon Tyne Freeman Hospital
Biopsy and pleurodesis:
Although a diagnosis can be made by a syringe and needle, a more invasive procedure is often required to obtain direct tissue from the pleura; this is often done with the aid of a camera through a single small (1 inch) incision on the side of the chest-the fluid around the lung can be drained out, biopsies taken, and if the lung can expand, it can be lightly coated with about 5 gram of talc to help it to stick to the inside of the chest. In about 80% of cases, this gets rid of most of the fluid. Most patients stay in hospital about 4 days for this procedure.
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 Future
If surgery to try to cure this disease has a role, it will be in combination with other treatments.
