The Treatment of mesothelioma is a great challenge for surgeons. There are basically three modes of treating any mesothelioma:
These treatment modalities can either be used alone or in combination. The choice of treatment is patient specific depending upon various factors such as the stage of mesothelioma, its origin and location, metastasis if any and its extent, the pathological findings and also the patient’s age and his expectations.
Removal of the cancerous growth is the commonest option, however the type of surgery depends upon the expected results of the surgery.
Chest tube drainage and pleurodesis is usually effective for a symptomatic relief from pleural effusion. Pleural effusion at times is persistent and recurrent after initial drainage of the fluid. To combat this problem, the pleural space is usually closed using talc slurry or any other sclerosing agent that produces an adhesion.
Shunts can be placed to remove the fluid collection in the pleura. For this purpose a catheter that runs from the pleural to the peritoneal cavity is placed under the skin. This is more often a palliative procedure.
Pleurectomy, when used as a palliative procedure, is helpful for people whose tumor growth restricts proper lung expansion. It can be an effective way to control fluid collection.
Pleurectomy/Decortication - The goal of this surgery is to remove all gross tumor in stage I and selected Stage II. Some cases may require a simultaneous removal of lung (known as pneumonectomy). This usually happens when the tumor cannot be removed without the removal of lung tissue.
Cytoreductive Surgery is used in combination with a form of chemotherapy called IPHC. The objective of the surgery is to remove all or nearly all of the gross or visible tumor in the peritoneal cavity. The abdominal cavity is then treated with IPHC or Intra-Peritoneal Hyperthermic (heated) Chemotherapy (IPHC).
The use of chemotherapeutic agents to kill cancer is not new, however it cannot be considered as a curative treatment for mesothelioma. In mesothelioma, chemotherapy can be used to stop the spread or to slow down the tumour growth, to reduce the tumor size prior to surgery, or to wipe out remnants of disease process after surgery. In palliative care, it may be used to relieve symptoms. Chemotherapy is a treatment of choice for people who are unfit for surgical procedures.
Alimta (pemetrexed) is a new multi-targeted antifolate drug, which has been lately approved by the Food and Drug Administration (FDA) for use with Cisplatin. Alimta in combination with Cisplatin is used either for malignant pleural mesothelioma which is unresectable or if the patient is unfit for surgery. The This drug works by jamming the enzymes necessary for DNA copying and cell division. The drug is safe enough to be administered on an outpatient basis every 21 days.
- Surgical removal of the tumor
- Chemotherapy agents to fight the cancer
- Use of high-dose x-rays or other high-energy rays to kill cancer cells. (Also called radiation therapy.)
These treatment modalities can either be used alone or in combination. The choice of treatment is patient specific depending upon various factors such as the stage of mesothelioma, its origin and location, metastasis if any and its extent, the pathological findings and also the patient’s age and his expectations.
Surgery
Removal of the cancerous growth is the commonest option, however the type of surgery depends upon the expected results of the surgery.
Chest Tube Drainage and Pleurodesis
Chest tube drainage and pleurodesis is usually effective for a symptomatic relief from pleural effusion. Pleural effusion at times is persistent and recurrent after initial drainage of the fluid. To combat this problem, the pleural space is usually closed using talc slurry or any other sclerosing agent that produces an adhesion.
Pleuroperitoneal Shunt
Shunts can be placed to remove the fluid collection in the pleura. For this purpose a catheter that runs from the pleural to the peritoneal cavity is placed under the skin. This is more often a palliative procedure.
Pleurectomy
Pleurectomy, when used as a palliative procedure, is helpful for people whose tumor growth restricts proper lung expansion. It can be an effective way to control fluid collection.
Potentially Curative Surgeries for Pleural Mesothelioma
Pleurectomy/Decortication - The goal of this surgery is to remove all gross tumor in stage I and selected Stage II. Some cases may require a simultaneous removal of lung (known as pneumonectomy). This usually happens when the tumor cannot be removed without the removal of lung tissue.
For Peritoneal Mesothelioma:
Cytoreductive Surgery is used in combination with a form of chemotherapy called IPHC. The objective of the surgery is to remove all or nearly all of the gross or visible tumor in the peritoneal cavity. The abdominal cavity is then treated with IPHC or Intra-Peritoneal Hyperthermic (heated) Chemotherapy (IPHC).
Chemotherapy
The use of chemotherapeutic agents to kill cancer is not new, however it cannot be considered as a curative treatment for mesothelioma. In mesothelioma, chemotherapy can be used to stop the spread or to slow down the tumour growth, to reduce the tumor size prior to surgery, or to wipe out remnants of disease process after surgery. In palliative care, it may be used to relieve symptoms. Chemotherapy is a treatment of choice for people who are unfit for surgical procedures.
Alimt (Pemetrexed)
Alimta (pemetrexed) is a new multi-targeted antifolate drug, which has been lately approved by the Food and Drug Administration (FDA) for use with Cisplatin. Alimta in combination with Cisplatin is used either for malignant pleural mesothelioma which is unresectable or if the patient is unfit for surgery. The This drug works by jamming the enzymes necessary for DNA copying and cell division. The drug is safe enough to be administered on an outpatient basis every 21 days.
Alimta is administered as a 10-minute IV infusion followed by a 2-hour infusion of Cisplatin. Researchers claim that patients treated with a combination of Alimta and Cisplatin have longer remission periods and have had less pain and shortness of breath than patients treated with cisplatin alone. This phase III trial however revealed that a decrease in white blood cells might occur as a side effect of the chemotherapy.
Radiation therapy may be used alone or in combination with other treatment modalities. In radiation therapy, radiation is used to kill cancer cells and shrink tumors. External radiation uses a source of radiation that is outside the body. On the other hand, internal radiation involves inserting materials that produce radiation through thin plastic tubes into the area where the cancer cells are found.
Radiotherapy
Radiation therapy may be used alone or in combination with other treatment modalities. In radiation therapy, radiation is used to kill cancer cells and shrink tumors. External radiation uses a source of radiation that is outside the body. On the other hand, internal radiation involves inserting materials that produce radiation through thin plastic tubes into the area where the cancer cells are found.
Intensity Modulated Radiation Therapy (IMRT) is an aggressive combined modality approach, in which x-rays of varying intensities in conjunction with computer generated images are used to deliver targeted radiation directly to cancer cells, while reducing the amount of radiation to the surrounding healthy tissue. Radiation can also be used as palliative therapy to limit the spread of the tumor. This is mostly used in cases where an infective line is left open by invasive procedures.
It is important to note here that with recent advances in research and clinical trial, newer options of treatment are emerging practically every day. Several of these have further been discussed in the following chapter, which deals with clinical trials.
It is important to note here that with recent advances in research and clinical trial, newer options of treatment are emerging practically every day. Several of these have further been discussed in the following chapter, which deals with clinical trials.
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