Mesothelioma Treatment

IN SHORT

Treatment for mesothelioma may include surgery, chemotherapy and/or radiation therapy. Treatment is usually difficult and mostly carried out in specialized cancer centers which include a team of oncologists, surgeons, pulmonologists, nurses etc. The outcome of treatment primarily depends on the stage of the disease at diagnosis or how far it has spread by the time treatment is initiated.

The following discussion is only presented so that you understand what the current mesothelioma treatment options are. The decision about how and when to use any of the treatment strategies depends on your cancer care team. If you, my friend, have mesothelioma, I urge you to never hesitate to ask your physician about your treatment options, and also feel free to ask your doctor if s/ he has some experience in treating this disease – only a handful of cancer specialists have acquired the experience through treating a large number of mesothelioma patients. So take your time to understand what is presented below.

Generally your mesothelioma treatment options depend on the location of the tumor, pleural or the others. (Checkout what is mesothelioma to learn more about the different types of mesothelioma.) It also depends on the extent of spread of the tumor, stage I-IV. (Checkout mesothelioma staging to learn more.) Accordingly your treatment plan may include one or more of the following:
-Surgery
-Chemotherapy
-Radiation therapy
Your care team may comprise of oncologists, surgeons, pulmonologist, nurses etc.

Surgery for Mesothelioma
Surgery can be done for diagnostic, palliative or curative reasons. Many of the curative surgeries currently underway often leave some cancer cells behind. These cells may later divide causing a relapse of the cancer. So in this case the surgery only provides extension of life.
Palliative surgeries become an option if the tumor is widespread (like in stage IV) or the patient is deemed not fit for an extensive operation. Similarly this surgery provides extension of life. So the difference as to the roles of the two types of surgery may not be clear at the moment. One thing that deserves mention is the fact that the surgeon may not tell the full extent of the tumor and therefore which type of surgery may be best - until the surgery has started.

Surgery for Pleural Mesothelioma
Pleurodesis – involves complete drainage of pleural effusion by tube thoracostomy or video thoracoscopy with later administration of irritative agent into the pleura to obliterate the space.
Parietal pleurectomy and decortication – pleura lining the chest wall on the same side of the tumor, pleura lining the lung, pleura lining the mediastinum and diaphragm are removed. The diaphragm and the lung are spared.
Extended pleurectomy and decortication – extensive version of the above operation in which the diaphragm and the pericardium are removed additionally.
Radical extrapleural pneumonectomy – a more invasive one in which, in addition to the above procedures, the lung is also removed. Ideal patients for this operation are younger than 65 years old, have pure epithelial histology, physiologically able to tolerate lung removal, have no lymph node involvement. Side effects with this approach include atrial fibrillation, herniation of the heart or abdominal contents, bronchopleural fistula, respiratory failure. This procedure is not the standard of care or should not be considered so. Postoperative mortality rate reach 4% at the earliest stages.

Surgery for Peritoneal Mesothelioma
Cytoreduction and intraperitoneal chemotherapy – since most of the peritoneal mesothelioma is confined to the peritoneal cavity, removing as much of the mesothelioma as possible may be desirable. Intraperitoneal (IP) administration of chemotherapy may be preferred to systemic administration due to the higher rate of absorption. Direct penetration into tumor cells may be limited in which case heating the chemotherapy may enhance the effect. Hyperthermic intraperitoneal chemotherapy (HIPEC) is an example.

Surgery for Pericardial Mesothelioma
Surgery can remove the tumor from the pericardium.

Surgery for tunica vaginalis testis mesothelioma
Surgery can’t remove the tumor entirely. Most of the time the surgery is intended for hernia and later realized that the patient is having mesothelioma not hernia.

Radiation therapy for Mesothelioma
Radiation therapy can provide palliation of symptoms in up to 50% of patients. It can also be used after surgery to kill what is left of the surgery. This is called adjuvant radiation therapy. External beam radiation therapy (EBRT), where the source of radiation is outside the body, is commonly used. (Intensity modulated radiation therapy is the advanced form.) Brachytherapy, where the source of radiation is inside the body, is another seldom used option.

Chemotherapy for Mesothelioma
Chemotherapy is applied either systemically or through an open cavity during surgery. A combination of cisplatin and pemetrexed are commonly used. Other agents include methotrexate, vinorelbine, mitomycin, doxorubicin, epirubicin, cyclophosphamide, ifosfamide.

One approach with some promise is intrapleural instillation of a replication-deficient, recombinant adenovirus where a gene for the herpes simplex virus thymidine kinase gene is inserted, thus making tumor cells sensitive to the normally nontoxic antiviral drug ganciclovir.