Injured

Mesothelioma

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Malignant mesothelioma is the most serious of all asbestos-related diseases. Although uncommon, mesothelioma is no longer considered rare. Mesothelioma is a cancer that is particulary difficult for doctors to diagnose and one that does not respond well to therapy.

The chest cavity, abdominal cavity, and the cavity around the heart are surrounded by a a layer of specialized mesothelial cells. Most other internal organs are also covered by these cells. The tissue formed by these cells is called mesothelium.

A special protective lubricating fluid that allows organs to move around is produced by the mesothelium. This protective fluid helps the lungs to move without resistance inside the chest cavity while breathing. The medical name for the mesothelium of the chest is the pleura and the medical name for the mesothelium of the abdomen is the peritoneum. The mesothelium of the "sac-like" space around the heart is called the pericardium.

A malignant (cancerous) tumor of the mesothelium is called a malignant mesothelioma. As most mesothelial tumors are cancerous, malignant mesothelioma is often simply called mesothelioma. Tumors of the mesothelium can also be benign (noncancerous) but benign mesotheliomas are much more rare.

Mesothelioma was recognized as a tumor of the pleura, peritoneum and pericardium in the late 1700's. However it was not until much later, in 1960, that this particular type of tumor was described in more detail and even more importantly, its association with asbestos exposure was recognized. The first report linking mesothelioma to asbestos exposure was written by J.C.Wagner, and described 32 cases of workers in the "Asbestos Hills" in South Africa. Since than the relationship between mesothelioma and asbestos exposure has been confirmed in studies around the world.

The incidence of mesothelioma in the United States remains very low, with 14 cases occurring per million people per year. Despite these numbers the noticed threefold increase in mesothelioma in males between 1970 and 1984, is directly associated with environmental and occupational exposure to asbestos, mostly in areas of asbestos product plants and shipbuilding facilities.

Although the disease is much more commonly seen in 60-year old men, it has been described in women and early childhood as well. The cause of the disease is not so well understood in these latter two groups, but there is some evidence of possible asbestos exposure for some of these cases as well.

Malignant mesotheliomas are divided into three main types. About 50% to 70% of mesotheliomas are the epithelioid type. This type has the best prognosis (outlook for survival). The other two types are the sarcomatoid type (7%-20%), and the mixed/biphasic type (20%-35%). Treatment options for all three types are the same.

About three-fourths of mesotheliomas start in the chest cavity. They are known as pleural mesothelioma. Another 10% to 20% begin in the abdomen. These are called peritoneal mesothelioma. Pericardial mesothelioma, starts in the cavity around the heart, and is very rare. The covering layer of the testicles is actually an outpouching of peritoneum into the scrotum. Mesotheliomas that affect this covering of the testicles are quite rare.

What is Mesothelioma?

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Throughout the past decade, the term "mesothelioma" has become more and more recognizable. Once an obscure disease that meant little to the general public, mention of this disease now conjures up thoughts and pictures of factories and mines strewn with asbestos and the unfortunate workers who were employed in those dangerous places.

Thanks to concerned medical professionals, researchers, and watchdog organizations, we're learning more and more about mesothelioma and how it affects the lives of those who are afflicted. However, there's still far to go as both better treatments and a cure for the disease are sought.

About the Disease

Simply put, mesothelioma which is commonly referred to as asbestos cancer, is an aggressive cancer caused primarily by the inhalation of dangerous asbestos fibers. The disease attacks the mesothelium, a protective, two-layered membrane that covers the internal organs of the body including the lungs, heart and abdominal organs. Between these layers, the cells produce fluid, which allows easy movement of the heart and lungs within the chest cavity. The layer that covers the lungs is called the pleura, and the layer that covers the heart is called the pericardium. The peritoneum lines the abdominal cavity. Mesothelium also lines the male and female reproductive organs. Mesothelioma can affect any of these cells, but is usually seen in the pleural or peritoneal mesothelium. The most commonly diagnosed form of this cancer is pleural mesothelioma.

Mesothelioma takes anywhere from 20 to 50 years to develop, which is why older individuals are usually the victims. However, recent cases involving September 11th World Trade Center first responders and clean-up crews show that high concentrations of asbestos can cause the disease to develop much more rapidly. A few WTC workers have already died of the disease.

Effects of the Disease

The invasion of the mesothelium by cancer cells makes it very difficult for the patient to breathe, resulting in the need for oxygen, especially as the disease progresses. Those with the pleural form of mesothelioma may also suffer from pleural effusions. These effusions prevent the smooth movement of the lungs and other organs in the chest. Peritoneal mesothelioma also affects the stomach area and abdominal cavity, causing nausea, vomiting, or loss of appetite, which can result in dangerous weight loss. In addition to breathing difficulties and loss of appetite, mesothelioma victims also complain of excessive coughing, sleeping difficulties, persistent chest pain, fever, and pain in the lower back.

Mesothelioma, in general, is a very painful disease and because it is usually not diagnosed until it's in an advanced stage. For this reason, the symptoms are typically quite serious. Late diagnosis also means that the cancer is more likely to have metastasized, or spread, making successful mesothelioma treatment even more difficult.

Who Gets Mesothelioma?

Statistics show that, because of their work history, the disease most often affects men between the ages of 50 and 70 who were employed in an asbestos-laden environment before asbestos warnings and bans were in place in the 1970s. Though women still have a much lower frequency of the disease, cases of second-hand exposure to asbestos has prompted more diagnoses among women, especially those whose male family members worked with asbestos. The occupations most associated with mesothelioma are shipyard workers, electricians, plumbers, construction industry workers, pipefitters, boilermakers, and anyone subject to heavy exposure to dangerous asbestos and airborne asbestos fibers.

An abundance of cases have also demonstrated that mesothelioma can develop among people who lived in communities where asbestos factories or mines were located. In some instances, entire towns have been adversely affected by the presence of asbestos fibers in the air. For example, in Libby, Montana - site of a former vermiculite asbestos mine - hundreds have already died of mesothelioma.

Though still significantly rarer than other cancers, an estimated 2,000 to 3,000 new cases of mesothelioma are diagnosed each year in the United States. Other countries, notably the United Kingdom and Australia, report a much higher incidence of the disease. Nevertheless, the United States - like many other countries - has seen an increase in asbestos-caused cancer as men who worked in U.S. shipyards in the 1940s and 1950s, at the height of production, are now being diagnosed with mesothelioma.

Dealing with Mesothelioma

Mesothelioma is most often diagnosed in its late stages, and such a diagnosis is devastating to the individual and his/her family. Though research into the disease has been ongoing, there is currently no cure for mesothelioma. Some patients may be candidates for surgery to remove tumors or even an entire lung, but most are better treated with radiation or chemotherapy. More often than not, these treatments are palliative, serving to lessen the severity of the symptoms of the disease rather than offering a cure.

Medical professionals and research scientists, however, are constantly exploring new ways to combat the disease. For example, doctors know that some combinations of chemotherapy drugs work better than others and tests developed to ascertain earlier diagnosis of the disease or to monitor those most at risk have arrived on the scene.

Who's to Blame?

The reason someone develops mesothelioma is usually the lack of proper protection offered to those who worked with asbestos. Though the dangerous properties of asbestos and asbestos products have been evident for decades, many employers neglected to protect their workers from inhaling asbestos while on the job. It wasn't until public awareness of the dangers of the material were revealed in the 1970s that many employers began offering protective clothing such as respirators, gloves, aprons, and other such items to those working with asbestos on a daily basis.

Due to the negligence of employers, many companies who manufacture asbestos or products that contain asbestos have been subject to literally thousands of lawsuits filed by those who've been harmed by the material. Many of those lawsuits have come from individuals suffering from mesothelioma.

Radiation Therapy

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Radiation therapy is one of the oldest and most frequently prescribed treatments for a variety of cancers, including mesothelioma. The American Cancer Society reports that about 60% of all cancer patients receive some form of radiation therapy. Somewhat less frightening than chemotherapy and surgery, radiation may be prescribed for the treatment of the disease itself or to help lessen the troublesome symptoms of a cancer such as pleural mesothelioma.

How Does Radiation Work?

High dose radiation kills cancerous cells that are found in the body of a person suffering from mesothelioma or any other cancer. Technically, the radiation destroys cancer cells at the molecular level and keeps them from reproducing. It is especially adept at killing cells that replicate quickly, such as those associated with mesothelioma.

Unlike chemotherapy, however, radiation therapy is a localized mesothelioma treatment which kills only the cells in the area to which the radiation is applied. It is not helpful in treating cancer which has metastasized - spread to other parts of the body.

Types of Radiation

Traditionally, there have been two types of radiation therapy available to cancer patients.

External radiation

The most common form of radiation therapy, external radiation is achieved by means of an x-ray machine which aims radioactive waves at the tumor or affected portion of the body. The procedure is fairly quick and is accomplished on an outpatient basis. How many radiation treatments a patient requires will depend on individual cases and include factors such as stage of the disease and size and location of the tumor.

Internal radiation

Also known as Brachytherapy, this type of radiation involves planting radioactive material into the cancerous tissue. It allows for the implementation of higher doses in a single treatment or is suggested for patients with tumors that are located deep inside the body and are unable to be reached by traditional external radiation. Patients must be admitted to the hospital for internal radiation, and because exposure to the patient may cause danger to others due to radioactivity, visitors will be limited for the first few days. Implants such as these may be temporary or permanent.

Radiation and Mesothelioma

Some mesothelioma patients are not candidates for radiation therapy while the treatment may be suggested for others. If also may be offered in tandem with other treatments, like surgery or chemotherapy.

While it is impossible for radiation to cure mesothelioma, doctors often suggest it as a palliative measure in order to relieve some of the uncomfortable side effects of the disease. Radiation therapy has proven quite successful in relieving pain as well as reducing instances of shortness of breath in mesothelioma patients.

Oncologists experienced in the treatment of mesothelioma will be able to determine if and how a particular patient might benefit from radiation therapy. If it is prescribed for you or a loved one, it is essential to stick to the schedule so that the patient receives the most benefit from the treatment.

What to Expect

Once your doctor has determined that you are a candidate for external radiation therapy, he/she will suggest an outpatient facility where you can receive the treatment. If internal radiation therapy is in order, you may be sent to a consult with a surgeon before you receive the treatment. He/she will set up a schedule of treatments as well. The schedule may involve days, weeks, or even months of radiation therapy.

While you will suffer the unpleasant side effects of surgery after Brachytherapy as well as some traditional radiation therapy side effects, the side effects of external radiation are quite mild compared to most other cancer therapies. The downside of radiation is that it can also destroy healthy cells along with cancerous cells. However, these cells will eventually begin to repair themselves.

The most common side effects of radiation therapy are:

Extreme fatigue
Redness near the treated area
Nausea
Vomiting
Dry mouth
Loss of appetite
Diarrhea
Hair loss (infrequent)
Decrease in white blood cells (leaving patient prone to infection)

Chemotherapy

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While the recommended mesothelioma treatment will no doubt vary from patient to patient and doctor to doctor, the form of cancer treatment most widely suggested is chemotherapy.

Dealing with the idea of chemotherapy can be equally as frightening as the initial diagnosis of mesothelioma. Chemo conjures up thoughts of treatments that cause horrible side affects and often leave the patient feeling worse than if they had no treatments at all. However, because advances in chemotherapy drugs and medications to lessen the side affects have decreased some of the unpleasant effects of chemo, patients should remain open to the idea of undergoing this type of treatment and should listen with an open mind.

How Does Chemotherapy Help?

Quite simply, chemotherapy - treatment with a specific cancer drug or combination of drugs - kills cancer cells. Unlike surgery and radiation therapy, which can destroy cancer cells in one particular location, chemotherapy can be used to destroy cells that have metastasized - or spread to other parts of the body.

There are currently about 100 chemotherapy drugs on the market. Though single chemo drugs are sometimes used to treat a particular type of cancer, more often a few of these drugs are used in tandem. This is called combination chemotherapy. Some combinations have proved more helpful than others in fighting mesothelioma and its troublesome symptoms. Because all of these drugs work a bit differently, your oncologist will determine which are best suited to treating your disease. The doctor will also be able to determine the length of your course of treatment as well as the frequency of treatments.

Types of Chemotherapy

Chemotherapy is received either by means of a pill or intravenously via a needle in the vein. Chemotherapy drugs may be administered 1) systemically - which means that the drugs are carried through the blood stream; or 2) intrapleurally - injected directly into the site of the tumor, with in the case of mesothelioma is usually the pleura, the lining of the lung. Doctors have had some success with both methods.

Chemo and Mesothelioma

Mesothelioma is a very aggressive form of cancer, so doctors treat it as aggressively as possible. That includes the use of highly toxic chemo drugs that will, hopefully, help destroy cancer cells while also providing some relief from the bothersome side affects of the disease, such as coughing, shortness of breath, and chest pain.

Years ago, doctors opted for single chemotherapy treatments for the disease. Unfortunately, they yielded little more than approximately a 15% success rate, providing minimal relief to the mesothelioma patient. More recently, oncologists and research scientists have determined that the best way to fight mesothelioma is through combination chemotherapy.

Currently, the drugs of choice are a newer drug, Alimta (pemetrexed), combined with Cisplatin, which has been on the market for some time. As a matter of fact, Alimta, when given with cisplatin, is the first and only chemotherapy drug to be approved by the Food and Drug Administration (FDA) for the treatment of patients with malignant pleural mesothelioma when surgery is not an option.

Other common chemotherapy drugs used to treat mesothelioma include gemcitabine, vinorelbine, and onconase. Researchers continue to experiment with new drugs and new combinations of chemotherapy medications in hopes that they can find the best available to treat the disease and its symptoms.

What to Expect

Chemotherapy is not a miracle drug, especially where mesothelioma is concerned, so it's necessary to be patient when dealing with the treatment. Most patients receiving chemotherapy for the first time will be especially concerned about side effects. Different chemo drugs have different side effects, but your doctor should be able to tell you what to expect.

Because your doctor has experience with specific chemo drugs, he/she may also be able to tell you when to expect the side effects, how long they'll last, and what to do about them. These days, there are many options available to help minimize or avoid these side effects so the chemotherapy of today is much different than that of decades or even years ago. Remember, also, that most of these side effects will disappear when the treatment has ended.

The most common chemotherapy side effects include:

Nausea
Vomiting
Low white blood cell count (which leaves you prone to infection)
Loss of appetite
Constipation
Fatigue
Fever and chills
Low platelet count (which may cause problems with clotting)
Generalized achy-ness
Tingling hands and feet
Rash
Depression

It's important to tell your doctor about any side effects you might experience, even if they are noted as "common" side effects of your chemotherapy. High fever, inability to eat or drink, blood in the stool or urine, and signs of infection should be addressed immediately. Your doctor will inform you about other side effects which he/she considers life-threatening.

Chemotherapy Drugs & Fact Sheets

A Mesothelioma Cure

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Following the backlash of asbestos-related exposures and illnesses, many people were wondering how scientific research was going to proceed. The response has been encouraging, with cancer specialists and other doctors working each day towards a cure for malignant mesothelioma. While a way to completely eliminate the cancer from the body does not presently exist, there are several successful mesothelioma treatment programs as well as clinical trials that are working towards developing a way to eliminate this unfortunate form of cancer.

Treatments for patients of malignant mesothelioma commonly fall in line with treatment of other lung and lung-related cancers. Curative treatments are those which remove the cancer from the body completely. While there are no cures for mesothelioma, any treatment could theoretically be curative, so long as it is successful in completely removing the cancer from the body. While the treatment may be curative, it is important to remember that curative treatments do not rule out the recurrence of the disease.

While curative treatments may not prevent the disease from recurring, it is important to be aware of current initiatives that are working towards a total cure for the disease. There have been instances of unique treatment programs that have prevented the recurrence of the disease for several years. Paul Krauss was diagnosed with mesothelioma in 1997 and given only a few months to live by his physician. Today, Paul Krauss is still alive and active and has dedicated himself towards spreading awareness of the disease and working with others in developing treatment programs that would be as successful as his has been.

Combination treatments, which integrate two or more different treatment options, such as surgery coupled with radiation, or surgery paired with radiation and chemotherapy have been successful in extending life expectancies. Researchers believe that when the right combination of therapies is found, prognoses will be far longer than anyone could have imagined when the disease first manifested. Technology has also afforded new possibilities to mesothelioma patients. CT (Computer Topography) scans have been able to map three-dimensional images of the body's internal organs for targeted chemotherapy or radiation therapy to be administered.

Another novel technique is being integrated with surgical resections of mesothelioma tumors. Heated chemotherapeutic agents have shown increased proficiency in the elimination of cancer cells. Side effects of chemotherapy have, in the past, prevented physicians from delivering an optimal dosage of the drug. However, a novel procedure known as intracavity heated chemotherapy treatment has integrated these two concepts into a successful program. Heated chemotherapeutic agent is administered directly to the affected area during the surgical removal, destroying any remaining cancer cells in the area and extending prognoses well beyond typical timeframs.

It is through technology and advancements such as these that cancer specialists and physicians are laying the groundwork for a cure.

A Patient's Options

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Once an individual has been diagnosed with mesothelioma, the next step is to discuss mesothelioma treatment options with his/her physician. Recent scientific research has produced significant breakthroughs with regard to treatment protocols for mesothelioma patients and more options are now available for managing the disease and supporting improved quality of life. Newly diagnosed patients always have many questions about the treatment options that would be most effective for them, including questions about new treatment therapies like Alimta and Cisplatin and other chemotherapy drugs. In addition to these newer drugs that are being used to treat asbestos cancer, mesothelioma patients also have a number of "conventional" treatment options to consider, including chemotherapy, radiation therapy and surgery. Clinical trials and experimental treatments are still other options that some mesothelioma patients may be eligible to participate in. Our site features a comprehensive mesothelioma cancer treatment section that includes important information for patients and families. We’ve included resources on top mesothelioma doctors such as Dr. Sugarbaker, as well as a comprehensive list of questions that you may wish to discuss with your personal physician when preparing a treatment plan. We are always providing new and informative resources regarding mesothelioma treatment including: Clinical Trials, conventional treatments, experimental therapies, and more. Check back often for the most recent advances in mesothelioma treatments.

Types

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What are the different types of mesothelioma?

Pleural Mesothelioma – affects the chest and lungs

Malignant pleural mesothelioma often originates within the chest cavity and can, at times, involve the lung. This particular form of mesothelioma can metastasize to numerous organs in the body – even the brain - and tends to do so more frequently than not.

Pleural mesothelioma is not always easily detectable. Frequently, in the early stages of the disease, symptoms may be mild. Patients usually report pain in one area of the chest that never seems to go away, weight loss and fever. Occasionally, other symptoms are more severe and include problems with breathing due to fluid build up in the chest. A CT Scan of the chest area has proven to be the best test for identifying how far along the disease has progressed.

Frequently serum markers are used to diagnose of various forms of cancer. Mesothelioma cannot be diagnosed using this method as no serum markers currently exist. If high levels of hyaluronic acid are present it may be possible to distinguish mesothelioma from other types of cancer or to determine the effectiveness of a treatment protocol.

The survival rate for patients diagnosed with pleural mesothelioma typically is not high. Patients typically do not live beyond seventeen months from the onset of symptoms. Only 8% of those diagnosed with mesothelioma will live three to five years from the onset of symptoms.

Pericardial Mesothelioma – affects the heart

Pericardial mesothelioma is the least common form of mesothelioma. Pericardial mesothelioma, as the name suggests, involves the heart. This rare type of mesothelioma invades the pericardium, the sac that surrounds the heart. As the cancer progresses, the heart is not able to deliver oxygen as efficiently to the body causing further decline in health at an increasingly rapid rate. The symptoms most commonly associated with pericardial mesothelioma mimic those of a heart attack: nausea, pain in the chest and shortness of breath.

Peritoneal Mesothelioma – affects the abdomen

Peritoneal mesothelioma originates in the abdomen and will frequently spread to other organs in area including the liver, spleen or bowel. Severe abdominal pain is the most common complaint that patients present to their doctor. There may also be a discomfort level with fluid build up in the abdomen as well. Other symptoms of peritoneal mesothelioma may include difficult bowel movements, nausea and vomiting, fever and swollen feet.

The survival rate is even worse for those diagnosed with peritoneal mesothelioma will patients typically surviving only ten months from time that they first started experiencing the symptoms noted above.

Malignant Mesothelioma

Malignant mesothelioma is an uncommon form of cancer and of all asbestos related diseases, the most serious. The symptoms associated with the disease make it difficult for doctors to diagnose. Often, by the time that a proper diagnosis is made, the disease has progressed to a point where patients do not respond well to treatment therapy. Malignant mesothelioma is caused almost exclusively by the inhalation of airborne asbestos particles. Another unique factor associated with the disease is that there can be a long latency period between the time an individual is exposed to asbestos and the actual manifestation of the disease in the form of malignant mesothelioma.

Benign Mesothelioma – affects the peritoneum

Cystic mesothelioma primarily affects women of younger age and affects the peritoneum. This type of mesothelioma is not frequently diagnosed and is also not a malignant form of the disease. It is, however, extremely difficult to identify and requires specialized microscopes and immunologic techniques to aid in diagnosis.

Mesothelioma in Uncommon Sites

A form of cardiac cancer that is rarely seen involves the pericardium. Tumors associated with this type of mesothelioma are not easily detectable and patients presented with this diagnosis tend to have a very low survival rate. There have also been reports of mesothelioma involving ovaries in women and the scrotum in men. Treatment for all of these rare forms of mesothelioma will vary depending on what stage a patient has progressed to but in most all cases the projected outcome is not favorable.

Glossary of Terms

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asbestos: combination of several minerals that separate into long, threadlike fibers. Because they do not burn, do not conduct heat or electricity, and are very resistant to chemicals, these minerals are often used for making fireproof materials, electrical insulation, roofing, filters, etc. benign: doing no harm, good incidence: the frequency with which an event occurs (usually in a group at risk) pericardium: a thin membrane surrounding the heart and the roots of the great blood vessels.

peritoneum: a thin membrane that covers the abdominal cavity and partially covers some of the abdominal organs.

pleura: a thin membrane that covers the lungs (visceral pleura) and lines the chest cavity (parietal pleura) malignant: harmful, dangerous (a malignant tumor is a cancer).

median: middle number in a series of numbers (for example: median survival of 10 months means that for that specific group of patients the survival varied from probably 2 months to 30 months).

mesoderm: the middle layer of cells in an embryo, from which the muscular, skeletal, vascular, connective etc. tissues develop.

mesothelioma: a tumor of the mesothelium, that can be benign (localized) or malignant (diffusely spread), and that is most commonly caused by the ingestion of asbestos particles.

mesothelium: the thin layer of mesodermal epithelial cells that forms the pleura, peritoneum, pericardium.

metastases: the spread of tumor cells from one part of the body to another unrelated part of the body by the way of the bloodstream or lymphatics.

prognosis: prediction of the probable course of the disease in an individual. Prognostic factors are factors associated with prognosis.

TNM staging: assigning a stage to the tumor based on size, local versus disseminated growth, lymph node involvement and presence or absence of distant metastases.

tumor: a mass of tissue, a growth independent of its surrounding structures and having no physiological function/ a neoplasm. A tumor can be benign or malignant.

Symptoms

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What are the warning signs of mesothelioma?

Mesothelioma is difficult to diagnose because the early signs and symptoms of the disease can be subtle at best. Symptoms are all too frequently ignored or dismissed by people who are inclined to attribute them to common every day ailments. Sometimes patients live with symptoms for up to 6 months before being diagnosed but usually the symptoms are present for two to three months prior to diagnosis.

About 60% of patients diagnosed with pleural mesothelioma experience lower back pain or side chest pain and there are frequent reports of shortness of breath. Lower numbers of people may experience difficulty swallowing, or have a persistent cough, fever, weight loss or fatigue. Symptoms to also consider are muscle weakness, loss of sensory capability, coughing up blood, facial and arm swelling and hoarseness.

Peritoneal mesothelioma originates in the abdomen and as a result, symptoms often include abdominal pain, weight loss, nausea, and vomiting. In the event that there is a hernia present, fluid build up may occur in the abdomen as well.

Anyone previously exposed to asbestos displaying any of these symptoms should seek medical attention right away.

Risk Factors

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What are the risk factors for malignant mesothelioma?

There are several risk factors that increase the likelihood that a person will develop mesothelioma. The primary risk factor is asbestos exposure. Exposure to this very harmful substance can significantly enhance the chances of contracting the disease. Other secondary factors include exposure to radiation, zeolite, simian virus 40 (SV40) and tobacco. We discuss each of these risk factors in more detail below.

Asbestos

Exposure to asbestos is the leading risk factor associated with mesothelioma. Asbestos is an insulating material comprised of magnesium-silicate mineral fibers. It was favored by builders and contractors for many years for its low heat conductivity and resistance to melting and burning. Since researchers have identified more and more links between mesothelioma and exposure to asbestos, the material is now less widely used. Prior to this discovery, however, millions of Americans have experienced serious exposure to this harmful substance.

Over 700,000 schools and buildings in the United States today contain asbestos insulation as reported by the US Environmental Protection Agency. Asbestos exposure doesn’t stop there, however. Asbestos is often found in ship yards, manufacturing facilities, railway facilities and construction sites. Blue collar workers are at the highest risk for developing mesothelioma due to occupational exposure and include those who work in mines, factories, shipyards, construction sites, railroads and for insulation manufacturers and gas mask manufacturers. The occupations most widely affected are miners, factory workers, railroad workers, ship builders and construction workers - especially those who install asbestos containing insulation. Sometimes family members related to the workers receive second hand exposure to asbestos from the dust and fibers that were brought home on the workers clothes and also become at risk for contracting mesothelioma.

Serpentine fibers and amphiboles are the 2 primary types of asbestos used. Chrysotile is a form of serpentine fiber and the most frequently used. These fibers tend to be curly and flexible. Amphibole fibers, however, are generally straight and thin and usually comprise one of five types: crocidolite, amosite, anthrophylite, tremolite, and actinolyte. The crocidolite type of Amphiboles is thought to be the leading contributor to cancer caused by asbestos. Serpentine fibers are dangerous as well, however, and have also been linked to mesothelioma.

Some research points to the fact that inhaled asbestos fibers cause a physical irritation resulting in cancer rather than the cancer being caused by a reaction that is more chemical in nature. As fibers are inhaled through the mouth and nose they are cleared from the body by adhering to mucus in the nose, throat and airways and then get expelled by coughing or swallowing. The Amphibole fibers (long and thin) do not clear as easily and it is therefore thought that they can embed into the lining of the lungs and chest and result in mesothelioma.

Asbestosis (scar tissue in the lungs) or lung cancer can also be caused by the inhalation of asbestos fibers. In fact, people exposed to asbestos are seven times more likely to develop lung cancer over the general public. Workers who sustain high levels of asbestos exposure are more likely to die from asbestosis, lung cancer or mesothelioma than any other disease. It is also believed that the action of coughing up and swallowing asbestos could contribute to a form of mesothelioma originating in the abdomen called peritoneal mesothelioma. Mesothelioma has been found to exist in other organs of the body as well such as the larynx, pancreas and colon, but those instances are extremely limited compared to lung cancer incidents.

The chance of developing mesothelioma is in direct proportion to the duration and amount of asbestos exposure that an individual sustains. Those who are exposed to high levels of asbestos at a young age, for long periods of time have a greater risk of being diagnosed with mesothelioma than those who have short, low level exposure. Another important consideration is that Mesothelioma can take a long time to manifest. Often, twenty to forty years can elapse from the time of exposure to diagnosis. Genetic factors can also play a role which explains why not everyone exposed to asbestos develops and asbestos related disease.

Radiation

Thorium dioxide (Thorotrast), a substance used in x-ray tests in the past has reported links to pleural mesothelioma and peritoneal mesothelioma. The use of Thorotrast has been discontinued for many years due to this discovery.

Zeolite

Some mesothelioma cases in the Anatoli region within Turkey have been linked to Zeolite, a silica based mineral with chemical properties similar to asbestos found in the soil there.

Simian Virus 40 (SV40)

Some scientists have found the simian virus 40 (SV30) in mesothelioma cells from humans and have been able to create mesothelioma in animals with the virus. The relationship between this virus and mesothelioma is still unclear, however, and further research is being conducted to gain clarity on this potential link.

Tobacco

Smoking alone is not linked to mesothelioma, but smokers who are exposed to asbestos have a much higher chance of developing lung cancer (as much as fifty to ninety percent higher). Research indicates that lung cancer is the leading cause of death among asbestos workers.

Stages

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How is mesothelioma staged?

Staging is the process of finding out how far the cancer has spread. Staging of mesothelioma is based on imaging studies such as x-rays, CT scans, and MRI scans. The treatment and outlook for patients with mesothelioma largely depends on the stage (extent of spread) of their cancer. Since pleural mesothelioma occurs most frequently and has been studied the most, it is the only mesothelioma for which a staging classification exists.

The staging system most often used for mesothelioma is the Butchart system. This system is based mainly on the extent of the primary tumor mass, and divides mesotheliomas into stages I through IV.

Butchart Staging System

Stage I: Mesothelioma is present within the right or left pleura, and may also involve the lung, pericardium, or diaphragm (the muscle separating the chest from the abdomen) on the same side.
Stage II: Mesothelioma invades the chest wall or involves the esophagus (food passage connecting the throat to the stomach), heart, or pleura on both sides. The lymph nodes in the chest may also be involved.
Stage III: Mesothelioma has penetrated through the diaphragm into the peritoneum (lining of the abdominal cavity). Lymph nodes beyond those in the chest may also be involved.
Stage IV: There is evidence of distant metastases (spread through the bloodstream to other organs).

Another staging system has recently been developed by the American Joint Committee on Cancer (AJCC). This is a TNM system, similar to staging systems used for most other cancers. T stands for tumor (its size and how far it has spread to nearby organs), N stands for spread to lymph nodes and M is for metastasis (spread to distant organs). In TNM staging, information about the tumor, lymph nodes, and metastasis is combined in a process called stage grouping to assign a stage described by Roman numerals from I to IV. Minor differences exist between the AJCC TNM staging system and the Butchart staging system.

TNM Staging System

Stage I: Mesothelioma involves the right or left pleura. It may also have spread into the lung, pericardium, or diaphragm on the same side. It has not yet spread to the lymph nodes.
Stage II: Mesothelioma has spread from the pleura on one side to the nearby peribronchial and/or hilar lymph nodes next to the lung on the same side. It may also have spread into the lung, pericardium, or diaphragm on the same side.
Stage III: Mesothelioma has spread into the chest wall muscle, ribs, heart, esophagus, or other organs in the chest on the same side as the primary tumor, with or without spread to subcarinal and/or mediastinal lymph nodes on the same side as the main tumor. Subcarinal nodes are located at the point where the windpipe branches to the left and right lungs. Mediastinal lymph nodes are located in the space behind the chest bone in front of the heart. Mesotheliomas with the same extent of local spread as in stage II that have also spread to subcarinal and/or mediastinal lymph nodes on the same side are also included in stage III.
Stage IV: Mesothelioma has spread into the lymph nodes in the chest on the side opposite that of the primary tumor, or directly extends to the pleura or lung on the opposite side, or directly extends into the peritoneum, or directly extends into organs in the abdominal cavity or neck. Any mesothelioma with evidence of distant metastases (spread to other organs through the bloodstream) or spread to organs beyond the chest or abdomen is included in this stage.

Although the recently developed TNM classification is the most detailed and precise, the original Butchart staging system is still used most often to describe the spread of pleural mesotheliomas. Understanding these staging systems for mesothelioma is important both for estimating and better understanding prognosis, and also for assessing therapeutic options.

Prognostic Factors

Because pleural mesothelioma has been better studied than peritoneal mesothelioma we know more about factors associated with prognosis for pleural mesothelioma. Younger age at diagnosis, performance status (functional status) and absence of weight loss are associated with a more favorable prognosis.

Mesotheliomas are usually of three different cell types (histological analysis): 1) epithelial cell type - has the most favorable prognosis; 2) fibrosarcomatous cell type - carries the worst prognosis and 3) mixed cell type - has an intermediate prognosis.

Mesothelioma Information

2009-04-17T08:47:00.001-07:00

As with any disease or health condition, mesothelioma researchers have, over time, collected statistical information about mesothelioma. These statistics can help us learn about the proclivities of the disease and its incidence and potentially help future patients as we learn more about mesothelioma.

Incidence of Diagnosis

New cases of mesothelioma are diagnosed in between 2,500 and 3,000 Americans each year. These numbers, while significant, would indicate that mesothelioma is still a relatively rare disease, though incidence is expected to rise in the next decade according to projections.

Age at Diagnosis

The first diagnosis of mesothelioma typically occurs in men and women between the ages of 50 and 70 years. Mesothelioma patients, certainly, have been diagnosed at ages younger than 50 and older than 70, but diagnoses for those age groups are considered statistical anomalies.

Does Mesothelioma Occur in a Particular Sex or Racial Demographic More than Another?

Mesothelioma is much more common in men than women, due mostly to occupational asbestos exposure being more common among men of industrial labor sites. That is not to say, however, that women cannot be diagnosed with mesothelioma. In fact, recent evidence suggests that mesothelioma incidence in women may rise in the coming years as secondary exposures to asbestos can manifest in the form of a positive mesothelioma diagnosis. Also of note is that mesothelioma is much less common among African Americans than white Americans, the reasons for which researchers are still investigating.

What are Typical Patient Survival Rates Following a Mesothelioma Diagnosis?

As mesothelioma is often diagnosed in its advanced stages, the prognosis is sometimes poor with life expectancy being little more than a year following diagnosis. If diagnosed early enough however, patient prognoses increase dramatically. Patient survival rates are often contingent on the treatments available to the particular patient. Early-stage tumors eligible for surgical resection, for instance, will result in improved prognoses over those diagnosed with later-stage disease. As new therapies and treatments are researched and employed in the future, it is realistic to anticipate an improvement in patient survival rates.

Diagnosis

2009-04-17T08:45:00.001-07:00

How do medical professionals diagnose mesothelioma?

If you believe that you may have mesothelioma, a qualified medical professional will use a variety of diagnostic tests and methods to confirm the presence of the disease.

Medical history review and exam

The first step that your health professional will take in evaluating you for an asbestos related disease is to obtain a full medical history to determine the level and severity of risk factors and presenting symptoms. This interview will look consider among other things, where you were exposed to asbestos, the length of exposure and the amount of asbestos that you were exposed to.

In addition, he/she will perform a medical exam to look for signs and symptoms of various forms of mesothelioma. For example, if pleural mesothelioma is suspected the doctor will look for fluid in the chest, peritoneal mesothelioma often shows fluid in the abdomen and pericardial mesothelioma presents with fluid in the area of the heart.

Diagnostic imaging tests

Chest x-rays are used to identify abnormalities in the lungs including unusual thickening, mineral deposits and fluid in the chest area. If these conditions are present then it may be evidence that mesothelioma has developed.

Diagnostic image tests like x-rays, CT scans and MRI's are useful in determining more information about the cancer including how far it is progressed. Each method provides another piece of information to your doctor to assist in making an accurate diagnosis. CT scans are capable of providing images of the same location from many different angles. MRI technology uses magnetic fields rather than x-ray to provide additional views.

Testing fluid and tissue samples

If fluid build-up in the chest, abdomen or heart area is present, your doctor may want to obtain a sample. To accomplish this he/she will use a long needle to obtain fluid from the target area. The fluid will then be sent to the lab for analysis.

A bronchoscopy procedure may be recommended for patients who are suspected of having pleural mesothelioma. For this medical test, a soft tube illuminates the trachea and bronchi to determine if any masses are present in the airways. If deemed necessary, the technician my take sample of tissue that appears to be abnormal for further testing.

If lymph node involvement is suspected which is common with lung cancer, patients may also undergo a mediastinoscopy. This procedure is similar to a bronchoscopy in that a soft tube enters the body under the chest bone and illuminates the chest area. In this way, the surgeon can examine lymph nodes for abnormalities, check to see how far disease may have progressed and when necessary help diagnose lung cancer vs. mesothelioma.

Diagnosing mesothelioma is never easy. Fluid build up alone in the chest, belly or heart regions is not enough to confirm a diagnosis. Tissue samples obtained from biopsy procedures are also difficult to discern because mesothelioma cancer cells often resemble other types of cancer. For this reason, specialized laboratory procedures are often employed to identify certain chemicals that are known to exist with mesothelioma and high powered laboratory equipment is used to examine the smallest details of cancer cells to confirm that mesothelioma is present.

Anti-cancer Drug

2009-04-17T08:44:00.003-07:00

Tuesday morning, Alfacell Corp. said that according to the research findings published in National Academy of Sciences Journal, the company's anti-cancer drug Onconase might be one of the most effective methods of treatment for mesothelioma and lung cancer caused by asbestos.

Onconase is a novel anti-cancer drug for the treatment of patients with inoperable malignant mesothelioma. Malignant mesothelioma is an asbestos-related cancer of the inner lining of the chest and abdomen.

The research findings have also identified the molecular mechanism by which asbestos provokes lung cancer that so far has remained difficult to understand.

Asbestos is made of tiny fibres, which are inhaled when one comes in contact with it. This triggers the release of TNF-Alpha, a cytokine, which leads to a series of biochemical events. The release of TNF-Alpha activates NF-KappaB (Nuclear Factor-Kappa B) protein, a transcription factor. This transcription factor protects asbestos-damaged cells against cell death. As a result the damaged cells gets accumulated leading to cancer.

According to the research journal, as Onconase inhibits the same pathways that lead to mesothelial cell malignant transformation and mesothelioma, the drug might show unique promise in preventing and treating mesothelioma and lung cancer.

Alfacell said that Onconase's efficacy in preventing mesothelioma in high-risk cohorts is soon to be tested because of its minimal side effects.

Experimental Cancer Drug Tarceva

2009-04-17T08:44:00.002-07:00

NEW YORK (Reuters Health) - OSI Pharmaceuticals Inc. is more confident than ever of the potential of its experimental cancer drug Tarceva (erlotinib HCl), even after the failure of a similar drug in a major clinical study this summer, OSI Chairman and CEO Dr. Colin Goddard told investors at the UBS Warburg Global Life Sciences conference here on Wednesday.

In August, AstraZeneca Plc. announced that adding its investigational non-small cell lung cancer (NSCLC) drug Iressa to standard therapy did not improve survival in a phase III trial of patients who had failed prior chemotherapy. The news raised concerns about a new class of cancer drugs expected to be effective with fewer side effects than other therapies.

Iressa is an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor. These kinds of drugs are believed to cause fewer adverse events because they target specific proteins associated only with tumors.

Since Tarceva is also an EGFR inhibitor, many industry watchers began to worry that the drug, which is still being evaluated in a phase III trial of NSCLC patients, might also fail to meet expectations.

But Dr. Goddard dismissed these concerns on Wednesday, noting that while similar, Iressa and Tarceva are structurally different. But more importantly, he said, the companies' approaches in evaluating their respective drugs are very different, as well.

Dr. Goddard told Reuters Health that in its failed trial, AstraZeneca was using doses of Iressa one-third to two-thirds of the maximum tolerable dose. OSI is using the highest tolerated dose of Tarceva.

Interestingly, he said, one of the side effects of Tarceva treatment is rash, and "what we find is when we produce rash, patients tend to do very well. In other words, there's a suggestion that pushing dose has real benefit in terms of survival."

"Hence, our whole rationale and belief is that we will see a differentiation between [Iressa and Tarceva] on the basis of that [dosing] strategy."

The OSI study is expected to complete patient accrual by the end of the year. Dr. Goddard said that OSI expects Tarceva to receive a six-month priority review by the US Food and Drug Administration after it is submitted.

Anti-cancer Drug

2009-04-17T08:44:00.001-07:00

The research findings have also identified the molecular mechanism by which asbestos provokes lung cancer that so far has remained difficult to understand.

Alfacell said that Onconase's efficacy in preventing mesothelioma in high-risk cohorts is soon to be tested because of its minimal side effects.

A Case Report: Malignant Mesothelioma with Unexpected Contralateral Mediastinal Shift

2009-04-17T08:43:00.001-07:00

Case Introduction: An unusual clinical feature of mesothelioma is the presentation of contralateral mediastinal shift due to pleural mesothelioma tissue, rather than a pleural effusion.

Case Summary: A woman, 63 years of age, who had been treated in the past for invasive ductal carcinoma of the breast, presented with chest pain and breathlessness. A radiograph of the chest revealed that she had contralateral mediastinal shift. Her symptoms were relieved after drainage of over 3 litres of pleural fluid.

Further investigations that she underwent revealed pleural mesothelioma rather than metastatic breast cancer which was expected. A few months later she again re-presented with breathlessness and a contralateral mediastinal shift was also again demonstrated in a chest radiograph.

On this occasion, a thoracic ultrasound revealed only a small loculated pleural effusion and, surprisingly, a large amount of malignant tissue which explained what was appearing in the chest radiographs.

Case Conclusion: This case illustrates that the mesothelioma tissue itself caused the mediastinal shift away from the affected side, not a pleural effusion which usually causes contralateral mediastinal shift in mesothelioma cases.

Mesothelioma Subtype Shows Lengthier Projected Longevity: IASLC

2009-04-17T08:43:00.000-07:00

SEOUL, Sept. 21 -- Some malignant mesothelioma patients may have a prognosis that's not as grim as once widely believed, said a Nordic collaborative group.

Patients diagnosed with epithelial subtype mesothelioma and treated solely with chemotherapy had a median survival of 15 months, while some patients survived beyond three years. This was reported at the International Association for the Study of Lung Cancer meeting by Gunnar Hillerdal, M.D., of the Karolinska University Hospital in Stockholm and colleagues.

The Nordic group experience contrasts with a clinical perception that mesothelioma patients usually die within a year, the investigators noted. A large multicenter trial based in the U.S. demonstrated a 12 month survival rate when using cisplatin with or without pemetrexed versus nine months with cisplatin alone. Other trials have yielded similar results.

Dr. Hillerdal said, "The Nordic Mesothelioma Group experience is different."

Surgery is used sparingly in treating mesothelioma in the Nordic countries. Dr. Hillerdal said, elsewhere in the world, patients with the most favorable characteristics (such as good performance status and lower-stage disease) often are recommended for surgery, leaving patients with the worst prognosis for chemotherapy treatment.

Data on 147 mesothelioma patients treated with chemotherapy alone and followed until death or for a minimum of 18 months were analyzed by Nordic investigators. All the patients were given gemcitabine, carboplatin, and liposomal doxorubicin.

In analyzing survival by histologic subtype it was seen that the epithelial subtype represented 108 patients (73%), 21 patients (14%) for the mixed subtype, and 18 patients (12%) for the sarcomatous subtype.

44% of epithelial subtype mesothelioma patients survived at least 18 months, 25% survived for two years, 9% lived three years or longer, and two patients remained alive after five years of follow-up. Those diagnosed with epithelial stage IV disease (distant metastases) had a median survival rate of 11 months, two lived for at least two years, and one patient was still living at 61 months.

Dr. Hillerdal remarked, "This is more favorable than stage IV non-small-cell lung cancer".

Patients with mixed subtype mesothelioma or sarcomatous disease had a less favorable outlook. This was demonstrated in a median survival rate of eight months and four months, respectively. There were no patients in either group that lived as long as two years.

"The key message from this study is that the survival rate for people diagnosed with mesothelioma is not as bad as many would believe," said Dr. Hillerdal. "Survival with chemotherapy can be just as good as with surgery or even better with proper patient selection. Patient selection is the important thing to consider. Stage is less important than subtype, and that should be kept in mind when evaluating results of surgical remedies."

Despite Onconase Trial Results Quintessence Moves Ahead

2009-04-17T08:42:00.001-07:00

In an article posted in this column a few weeks ago, it was reported that researchers at Madison-based Quintessence Bioscience were waiting for the results of a Phase IIIb clinical trial from Alfacell Corp., a significant East Coast competitor, on an anti-cancer therapeutic compound, Onconase. QBI-139, Quintessence's lead drug candidate, is very similar to Onconase but has not yet gone through clinical testing.

Upon the release of the Onconase trial results, Ralph Kauten, Quintessence Chairman and CEO commented that he was "disappointed that the Onconase clinical trial results were not reported to be overwhelmingly successful."

In a communication that Quintessence sent to its shareholders about the Alfacell trial, Kauten shared the following:

"Data has been released by Alfacell showing that their first-in-class drug, Onconase, did not meet the primary endpoint in the Phase IIIb confirmatory trial for malignant mesothelioma. The trial involved a comparison of a combination of Onconase plus doxorubicin versus doxorubicin by itself. The intended primary endpoint was an overall increase in patient survival. Initial analysis of Alfacell's data showed no statistically significant improvement for patients evaluated after taking the doxorubicin and Onconase combination."

Alfacell, in other words, tested whether treating mesothelioma patients with a combination of Onconase plus the standard chemotherapy drug, doxorubicin, would increase their survival at a statistically significant rate vs. those treated with doxorubicin alone. Mesothelioma is a very difficult cancer to treat and is generally related to asbestos exposure. Upon analysis of the data, there was no significant difference in survival rates when comparing the two therapeutic approaches which indicates that the patient survival rate was not favorably impacted by adding Onconase.

When the data were examined more closely, however, it became evident that a subset of patients failing the standard chemotherapy approach for treating mesothelioma, showed a small but statistically discernable increase in survival when they were treated using Onconase. It is based on the results of these data that Alfacell intends to submit an application to the FDA that would allow the use of Onconase as a "second-line" therapy for mesothelioma patients who do not respond to traditional chemotherapy. The FDA has not reacted favorably to this type of sub-group analysis of data in the past so it is unclear how they will respond to the application. Traditionally, they have not favored this type of analysis, but because there are emerging indications of a change in that attitude, Alfacell is continuing with the process for getting the new drug approved.

Is there reason to be concerned?

It was asked again if there should be any concern at Quintessence over these less than encouraging results from Alfacell. Despite the results, Quintessence remains committed to moving QBI-139 into clinical trials, most likely sometime this summer. In their communique to shareholders, Quintessence also explained the following:

"Getting Onconase approved is made more challenging because it failed to meet the primary endpoints in the Alfacell Phase IIIb trial. Onconase, however, still has major potential to get approval for use as a second line treatment therapy for malignant mesothelioma. This change would create a smaller market for the drug, but we continue to be of the opinion that the road to general acceptance of RNases as cancer therapeutics will be paved by any successful FDA approval of Onconase."

It was further reported that "Quintessence continues to progress toward filing an IND and starting a Phase I clinical trial for QBI-139. Most of the data that supports the IND has been collected and analyzed and GMP manufacturing is taking place. We are in contract negotiation with the clinical trial site and a contract monitoring group. We look forward to being able to demonstrate the clinical benefit of QBI-139 in patients who have been diagnosed with cancer."

The future of RNase-based therapies that Alfacell and Quintessence are developing hinges on the FDA's response to Alfacell. Unfortunately, if a drug is tested on the wrong disease and fails, it is difficult to try to test it on another, more appropriate, disease. If a drug gets a bad reputation, NIH grant reviewers and investors may not respond enthusiastically.

Testing Onconase on mesothelioma may turn out to be a bad decision on the part of Alfacell, but it was still an interesting strategic decision made by the company. Alfacell chose Mesothelioma for the initial clinical trials because of the stubbornness that Mesothelioma exhibits in response to traditional therapy. As a result, the FDA granted Onconase fast track status and orphan-drug designation and Onconase was able to get into advanced clinical trials much sooner that it would have otherwise.

The results that have been demonstrated by Onconase do not mean that RNase-based therapies will not work on other types of cancers and there is still reason to believe that Quintessence's lead RNase therapy, QBI-139 will be even better than Onconase.

Sex difference in diffuse malignant peritoneal mesothelioma.

2009-04-17T08:39:00.003-07:00

BACKGROUND: Diffuse malignant peritoneal mesothelioma (DMPM) is rare and in the past has proved an invariably fatal disease. Female patients have been reported to have an improved survival outcome for reasons that are not understood. METHODS: The survival of 34 men and 28 women who underwent cytoreduction and perioperative intraperitoneal chemotherapy for DMPM was compared. Twenty-five clinicopathological variables were subjected to univariate analysis. RESULTS: The women had a 5-year survival rate of 63 per cent and median survival was not reached. The men had a 5-year survival rate of 42 per cent, with a median survival of 32 months (P = 0.045). Women had undergone more extensive previous surgery and had less extensive peritoneal involvement at the time of cytoreduction. Tumours in women more frequently showed a small nuclear size (30 microm or less) and the chromatin pattern was more often granular than clear. CONCLUSION: Women with DMPM had better survival. This observation may be related to the favourable clinical and histopathological features associated with women.

>Q & A with Dr. Sugarbaker

2009-04-17T08:39:00.000-07:00

These are questions asked of Dr. Sugarbaker by a patient regarding a mesothelioma surgical procedure in January of 1997.

What exactly will be removed during surgery?

The surgery is called extrapleural pneumonectomy. It is removal of the left lung, the parietal pleura (lining of the lung), the ipsilateral pericardium (left side of the lining of the heart), ipsilateral diaphragm (left side of the diaphragm).

How many surgeries of this type for Mesothelioma have you performed?

250

Of those patients, what is the percentage survival rate?

The median survival rate is 41 months.

Of the patients who survived what was the quality of life?

The quality of life for most patients was fairly normal, some have even returned to work. Patients should not be oxygen dependent. Patients with epithelial cell type without lymph node involvement have a 2-5 year survival rate of 74% to 39% receptively.(Pg. 288 study)

How long of a hospital stay is required with this surgery?

A 5 to 10 day stay provided there are no complications.

How long will it take to recover from the surgery?

Complete recovery time is about a year.

How long after surgery will the chemotherapy and radiation start?

Chemotherapy will start about 4 to 6 weeks after surgery. There will be three cycles of therapy. One cycle of Taxol, one cycle of Carboplatinum and then the final cycle is with both chemo agents followed by 1 month of radiation. Total treatment time is 3 1/2 months and the recovery time.

Based on the test results of the MRI, Echocardiogram and V/Q scan, what stage is the asbestos cancer in?

Stage I because there is no evidence of lymph node involvement.

Based on the prior surgery on November 15, 1996, how long a wait before having surgery again?

The surgery can be performed now. They will use the same incision site.

What are the risks associated with the surgery?

Hemorrhage, respiratory failure, pneumonia, disrupted diaphragmatic patch, perforated duodenal ulcer, empyema (infection), upper gastrointestinal bleed, deep vein thrombosis, death.

Based on the additional tests, is the cancer localized to the left lung?

Yes. There was no evidence of the cancer in the chest wall, right lung, or in the diaphragm.

Current Therapy For Mesothelioma

2009-04-17T08:37:00.001-07:00

Malignant pleural mesothelioma is locally aggressive, invasive, and almost universally fatal.

INTRODUCTION

Mesotheliomas of the pleural cavity are relatively rare tumors. Generally, two types of pleural tumors can be referred to as mesotheliomas. The less common is the solitary (or localized) fibrous tumor of the pleura, previously known as "benign mesothelioma." This slow-growing, commonly benign, well- circumscribed tumor is pedunculated on a pleural-based pedicle and often is cured by resection. The tumor appears to originate from submesothelial rather than mesothelial or epithelial cells. The more common variety is the diffuse malignant pleural mesothelioma (DMPM), a true mesothelial malignancy that is locally aggressive, invasive, and almost universally fatal. This multicentric tumor infiltrates the pleural space, results in a pleural effusion, and mechanically compresses the surrounding structures. Though distant metastatic lesions may be seen in up to 30% of cases in autopsy series, most patients die of locoregional invasion and compression of vital structures. The median survival for patients with DMPM is between four and 12 months, depending on the stage at presentation.

BACKGROUND*: Diffuse malignant pleural mesotheliomas (DMPMs) are highly lethal tumors that are becoming more common. Standard management approaches have provided limited effectiveness.

METHODS*: The literature on management has been revised, and the authors present their data on outcomes for 120 patients treated with an aggressive trimodality approach.

RESULTS*: An aggressive trimodality approach including extrapleural pneumonectomy followed by chemoradiation produces low mortality and acceptable morbidity. The five-year survival rate in patients with epithelial histology and negative nodes approaches 40%.

CONCLUSIONS: Mesothelioma is increasing in frequency and presents many diagnostic and management challenges. An optimal universal staging system is still awaiting definition and validation. Prognosis is best for patients with localized disease and epithelial histology. Surgical techniques including pleurectomy/decortication and EPP can result in a major debulking of disease, and studies are ongoing to determine if the addition of chemotherapy and radiation has an impact on survival. Several new investigational approaches are now being tested, including intrapleural interferon gamma, photodynamic therapy, immunotherapy, and gene therapy.

Laparoscopy and mesothelioma

2009-04-17T08:36:00.001-07:00

Malignant mesothelioma is a well-recognized long-term sequela of chronic asbestos exposure. Asbestos use in the United States began in the 1950s and was widespread until the mid-1970s. Although currently only 2.2 cases per million population per year are diagnosed, disease incidence is increasing because of the long latency of this neoplasm. A latency of 15-50 years means that a higher incidence of this neoplasm can be anticipated in the future. The authors report a patient with peritoneal mesothelioma and no known prior exposure to asbestos. The diagnosis was confirmed by exploratory laparoscopy, which entailed biopsies of the diaphragm and of the peritoneal and abdominal walls, and by cytologic evaluation of 700 ml ascitis fluid. At present, exploratory laparoscopy offers the quickest, safest, and least invasive way to confirm the clinical diagnosis of peritoneal malignant mesothelioma.

Current problems in the diagnosis of malignant pleural mesothelioma.

2009-04-17T08:35:00.001-07:00

The diagnosis of malignant pleural mesothelioma (MPM) is challenging although MPM is highly aggressive tumor. The current diagnostic gold standard is principally based on light microscopic examination of hematoxylin-eosin and immunohistochemical stains of large tissue sections. However, pathological diagnosis of MPM and classification of histological findings into 1 of the 3 subtypes (epithelial, sarcomatoid, biphasic) are difficult. We studied correlation between initial and final histological diagnosis retrospectively from the records of 21 cases with MPM from 1989 to 2005. The diagnosis of MPM was confirmed by histopathological examination of pleural tissue samples obtained by closed biopsy under computed tomography (CT) or ultrasonography-guided (5 cases), by biopsy under thoracoscopy with local anesthesia (9), by open biopsy via thoracotomy (2), and by video-assisted thoracoscopic surgery (VATS) [5] . Pleural biopsy under those diagnostic methods led to initial diagnosis of MPM in 15 of 21 cases (71.4%) . In 6 cases (28.6%) , initial diagnosis of MPM were not confirmed because of missing malignant tissue (1 case) and relatively small and sarcomatous element (5). In 2 cases examined by closed biopsy and in 3 examined by thoracoscopy under local anesthesia, initial diagnosis of MPM were not confirmed. To get the accurate diagnosis of MPM, obtaining large tissue samples in the initial examination by less invasive thoracoscopy is recommended.

Managing Your Medical Expenses

2009-04-17T08:12:00.001-07:00

The volume of paperwork involved in managing insurance claim forms, co-pays, benefits statements, etc., can be overwhelming for a mesothelioma patient who is trying to concentrate on their health care, but by keeping organized, accurate records, you can eliminate unnecessary stress.

Perhaps the simplest way of keeping information to be referred to when filing an insurance claim, is to use a paper calendar to make note of all doctor's appointments, lab tests, procedures and treatments, as well as prescription drugs purchased. If this information is recorded on the day it occurs, you will have a complete chronological record when you need it. Other records you should organize in an expandable folder or binder include:

Bills from all health care providers.
Bills or receipts for prescription drugs.
Receipts from co-pays or other health care related costs.
Insurance claims filed.
Reimbursements received.

Keeping medical expenses entered on a basic computer spreadsheet is another option, or, there is specialized software available for those who prefer a better display of information and the ability to search for and sort information. One of these programs is the "Medical Expense Manager" offered by Quicken. This program will allow you to track and organize medical expenses, tax deductions, medical and prescription history for multiple individuals, insurance payments and deductibles and billing or claims disputes.

Another alternative is to hire someone to manage your claims for you, and if you feel you need professional help, there are health insurance claims assistance services available in many areas. These professionals can file and track claims, contact health care providers and insurance companies to resolve claim issues, review medical bills for accuracy and appeal rejected claims. Fees for services rendered can vary significantly according to provider.

For those with Medicare coverage, a health insurance assistance program is available in every state. Counselors can help Medicare recipients understand their benefits, and can make suggestions on establishing a record keeping system.

Keeping a Personal Medical Records File

2009-04-17T08:11:00.001-07:00

When you or a family member is going through the diagnostic process, or are being treated for mesothelioma, it is an undeniable fact that there will be a multitude of paperwork and reports involved. Although each individual medical professional or facility will keep its own record of your care, it is also important that you maintain an accurate, up to date medical history of your own.

It is likely that several different doctors, possibly at various locations, will be involved in your care, and each will generate a series of test results, treatment reports, scripts for medications, etc. By consolidating and organizing this information in one file, you will always have access to what you need if questions arise, or if a report is lost or inadvertently destroyed. It will also give you an opportunity to go over your records in your own time, and make note of any questions or concerns you might have. In this way, you will become a more active participant in your health care, and will feel more knowledgeable and in control of your situation. Keeping a personal medical file is also helpful in managing your health insurance claims, taxes and other legal matters.

Your personal medical record file should include the following:

Information on past medical history, including the dates and details of any previously diagnosed illnesses such as diabetes or heart disease.
Information on past physical examinations and screening tests.
Immunization records.
Contact information for all doctors, clinics and/or hospitals involved in your diagnosis, treatment or other care.
Dates of initial diagnosis and a schedule for subsequent treatments.
Copies of reports and diagnostic tests, including laboratory results, pathology reports and imaging tests (x-ray, CT, MRI, PET).
Treatment information including surgical reports, names and dosages of drugs used for chemotherapy and sites and dosages for radiation therapy.
Notes on treatment results including any complications or side effects experienced.
Information on supportive care such as pain management or nutritional support. All medications you are taking, including prescription and over the counter drugs, should be listed by name, dosage and how often they are taken.

If you have been diagnosed with mesothelioma, it is best to collect information for your file each time you have an appointment, test or procedure. At each doctor appointment, ask for any records being added to your file, and if you have a laboratory test or a procedure of any kind, request a copy of the test results or the procedure report. If you are hospitalized for any reason, request a complete copy of your hospitalization records when you are released. Keep copies of medical bills and insurance claims.

How you organize your file is a matter of personal preference. Some people prefer a filing cabinet, while others prefer a folder, binder or box; some prefer to scan documents into a computer file. Records can be divided according to date or by category such as appointments, tests or treatments. However you choose to compile your file, be sure it is stored in a safe place. You may wish to leave an additional copy with a relative or friend in case of emergency.

The Health Insurance Portability and Accountability Act of 2003 assures that all patients have access to their medical records, so if you did not start a medical file when you were first diagnosed or treated, you can still obtain the information you need. In this case, it may be necessary to request your records in writing, and you may need to complete an "Authorization to Release Medical Information". Unfortunately, requesting records after the fact can take time, and you may be charged copying fees.

Managing Your Care

2009-04-17T08:10:00.001-07:00

Mesothelioma is a major challenge and keeping up with activities involving your treatment and doctor visits can be overwhelming. The patient, the family, and close friends are faced with new and unfamiliar experiences. A methodological approach to your care can often make life easier for everyone.

The concept of a personal medical file is becoming more popular, and these files can be especially useful for cancer patients who see multiple doctors and receive treatment at more than one location. The personal medical file helps ensure that you always have access to critical data (even when your doctor’s office is closed) and there is a backup of the most important documents. When you visit a new health care provider, you will have comprehensive access to the information they need. More on personal medical files.

Keeping track of the medications you are taking can be a hassle, especially given the amount of prescriptions the typical mesothelioma patient takes. You need to know what medicines you are taking, which doctor prescribed them, what the dosage is and how many pills a day you take. A formal file and notebook organizer can help here. More tips on managing your medications.

Keeping track of your expenses is important. Everyone has different financial resources, insurance coverage, and Medicare eligibility. Many mesothelioma patients can get compensation from the asbestos industry, which can help with medical costs. Whatever the source of your funding, you need to keep track of all bills from hospitals and clinics, bills from drugs stores, and insurance claims and payments. Tips on managing your expenses.

Because mesothelioma is a rare cancer, your doctor may not have much experience dealing with it. There is nothing wrong with getting a second opinion from another physician. Here are some ideas on second opinions. You may wish to look at our list of mesothelioma specialists. Contact us if you are interested in reaching these doctors. Note that the type of doctor that specializes in cancer treatment is called oncologists. However, because mesothelioma is so rare, even most oncologists have seen a limited number of cases. Also you may wish to look into the community clinical oncology program, sponsored by the federal government, which offer access to clinical trials to patients at cancer centers around the country.

Your Health Care Team

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A diagnosis of mesothelioma brings with it one of the most difficult challenges you or your loved one will ever face. One of the most important things to remember, however, is that there are resources to help with every aspect of care, and that you or your loved one is at the center of the health care team that will provide help in many different forms. Remember also that in addition to your doctor you can also get a second opinion from another physician.

You, the Patient

Your role as the most important member of the team is to be a good consumer by gathering information and asking questions. Following are some easy ways to make the most of your appointment times with other members of your medical team:

Once you know the day and time of your appointment, start a list of questions you want to ask that particular team member. These questions could be about mesothelioma itself, about test results or about treatments you are undergoing or considering. It is also a good idea to write down any symptoms you may be experiencing so that they can be addressed at this time. If there is something you don’t completely understand, ask to have it explained in simpler terms. Above all, don’t be embarrassed to ask questions or request clarifications.
If possible, take along another person who can take notes, ask additional questions or record your appointment for later review. Sometimes it can be helpful to return home and play back what was discussed.
Ask for written material or brochures that can help in making treatment or care decisions . These might include information on nutrition, pain management, support groups or hospice or home care.

Other than your doctors, who could include your primary care doctor, surgeons, medical oncologists, and/or radiation oncologists, you will probably have the most contact with your nursing staff and your social worker. These medical professionals can be your best source of practical assistance when trying to navigate the waters of a mesothelioma diagnosis.

Nurses

All specialized cancer treatment facilities have nurses who are familiar with implementing the cancer treatment plan initialized by your doctor, and are trained to administer medication, monitor side effects and conduct routine tests. Whether you are a hospital inpatient or outpatient, you can benefit greatly from developing a strong working relationship with your nursing staff.

You may also request home visits by a registered nurse, if necessary. If approved by your doctor, these visits may be covered under insurance. Be sure to check with your individual insurance provider for details.

Social Workers

Social workers are a good starting point for newly diagnosed patients who are overwhelmed by their diagnosis and the many things that have to be accomplished and decided.

Some types of social workers include:

Oncology social workers specialize in assisting those diagnosed with cancer. Most cancer treatment facilities have certified oncology social workers on staff.
Clinical social workers specialize in providing services aimed at family therapy and counseling, or counseling for those coping with a serious illness.
Hospital social workers can help find resources in your local area such as home care, transportation services or support groups, and can also help you understand your diagnosis, your treatments and other care options.

Psychiatrists and Psychologists

Because of the emotional issues surrounding a mesothelioma diagnosis, some patients or their family members may benefit from the help of someone trained to deal with depression, anxiety or inability to cope. Don’t be afraid to ask for this type of help for yourself or your loved one – good emotional health is essential to quality of life.

Psychiatrists are medical doctors who specialize in providing psychotherapy and other general psychological services to their patients. They are licensed to prescribe medications such as antidepressants and sleep aids. (Related: concerns about drug addition during cancer treatment.)
Psychologists can provide many of the same services as a psychiatrist such as counseling for depression, anxiety, etc., however, they are not medical doctors. Most have PhD’s in psychology and counseling.

Nutritionists and Dietitians

Nutrition is another area that can greatly affect quality of life. Many patients lose weight because of anxiety associated with the diagnostic process, subsequent treatments or the natural progression of mesothelioma. Working with a nutritionist or dietitian as soon after diagnosis as possible is one of the most important benefits you can obtain from your health care team. These professionals can help you be sure you receive enough calories, vitamins and protein to maintain a healthy weight, as well as tailoring a program for those with concurrent health problems such as diabetes or high cholesterol. They can also suggest ways to minimize the side effects of chemotherapy or other aggressive treatment.

Most local hospitals have registered dietitians on staff, or you can ask your doctor to recommend someone in your area. As with other health care needs, check to see whether these services are covered under your insurance. If they are not, there may be community-based services available in your area at no cost.

Hospice and Home Care

Hospice care is palliative in nature, and provides comfort care by helping to control a patient’s physical symptoms as well as offering emotional and spiritual support. Although in most cases, care is provided at home, there are also hospice facilities that provide full-time care in a hospital setting. You can discuss the benefits of hospice with your doctor, nurse or social worker.
Home care provides assistance in the home with daily activities such as bathing, meal preparation or household chores. These services are usually provided by a home health aide, and may or may not be under the supervision of a nurse. Ask your doctor, nurse or social worker for Home Health Care Agencies in your area.

FINDING A MESOTHELIOMA SPECIALIST

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The following physicians are specialists in the treatment of malignant mesothelioma. You will find links to their web sites, when available and to some of their published articles.They are listed in no particular order with no particular endorsement.

Mesothelioma is typically treated by an interdisciplinary team of doctors rather than by a single physician. You may run into professionals called oncologists, thoracic surgeons, and pulmonologists. Glossary of members of a thoracic oncology care team. More on choosing your mesothelioma doctor.

W. Roy Smythe, MD

Professor and Chairman/Department of Surgery, Texas A&M University System Health Sciences Center, Scott & White Hospital, Temple, TX
Phone: 254-724-2595

Dr. Smythe is currently accruing patients for a protocol involving extrapleural pneumonectomy and Intensity Modulated Radiation Therapy (IMRT). (Click here for an abstract of this trial).

Biography

David C. Rice, MD

Assistant Surgeon and Assistant Professor of Surgery; Director, Mesothelioma Program; Director, Minimally Invasive Surgery Program, Thoracic Surgery/The University of Texas M. D. Anderson Cancer Center, Houston, TX
Phone: (713) 794-1477

Dr. Rice is currently concluding enrollment on a Phase II trial of extrapleural pneumonectomy (EPP) followed by Intensity Modulated Radiation Therapy (IMRT). He is also anticipating the opening of a new trial of preoperative Alimta/Cisplatin, followed by EPP and IMRT.

Biography

David J. Sugarbaker, MD

Chief, Division of Thoracic Surgery/Brigham and Women's Hospital, Boston, MA Chief, Department of Surgical Services/Dana-Farber Cancer Institute, Boston, MA
Phone: (617) 732-6824

Dr. Sugarbaker believes in aggressive treatment of pleural mesothelioma. He is a proponent of tri-modal therapy; extrapleural pneumonectomy, chemotherapy and radiation.

Click here for an article by Dr. David J. Sugarbaker that appeared in the The Journal of Thoracic and Cardiovascular Surgery, January 1999 (12 pages in Adobe PDF format).

Biography

Lambros Zellos, MD, MPH

Attending Thoracic Surgeon; Clinical Co-Director of the International Mesothelioma Program/Brigham & Women's Hospital/Dana Farber Cancer Institute Harvard Medical School, Boston, MA
Phone: (617) 525-9657

Dr. Zellos is an Attending Thoracic Surgeon and the Clinical Co-Director of the International Mesothelioma Program. Dr. Zellos is a proponent of tailored multimodality therapy for each individual patient. Appropriate therapy may include surgery such as pleurectomy or extrapleural pneumonectomy with chemotherapy or radiation. Dr. Zellos has published several papers on multimodality therapy as well as methods to improve surgical techniques.

Valerie W. Rusch, FACS

Attending Thoracic Surgeon/Memorial-Sloan Kettering Cancer Center, New York, NY
Phone: (212) 639-5873

Dr. Rusch is known for the treatment of pleural mesothelioma. She has published several papers comparing pleural decortication to extrapleural pneumonectomy.

Biography

Raja M. Flores, MD

Attending Thoracic Surgeon/Memorial-Sloan Kettering Cancer Center, New York, NY
Phone: (212) 639-2806

Dr. Flores is currently the Principal Investigator on a clinical trial of neoadjuvant gemcitabine and cisplatin followed by extrapleural pneumonectomy and high dose radiation, as well as being involved in a trial of neoadjuvant Alimta/cisplatin, extrapleural pneumonectomy and high dose radiation. He has also compiled a 1,000 patient database to research areas of failure, and how to improve treatments for mesothelioma.

Biography

Paul H. Sugarbaker, MD, FACS, FRCS

Director, Surgical Oncology/Washington Cancer Institute, Washington, DC
Phone: (202) 877-3908

Dr. Sugarbaker is a specialist in the treatment of peritoneal mesothelioma using a combination of surgery, chemotherapy and radiation.

Brian W. Loggie, MD

Professor of Surgery, Creighton University Medical School; Chief, Division of Surgical Oncology; Director of Cancer Center/Creighton University Medical Center, Omaha, NE
Phone: (402) 280-4100

Dr. Loggie specializes in the treatment of peritoneal mesothelioma and peritoneal carcinomatosis. His protocol, based on eligibility, involves surgical debulking in combination with intraperitoneal heated chemotherapy.

Biography

David L. Bartlett, MD

Professor of Surgery, Chief, Division of Surgical Oncology/UPMC Cancer Pavilion, Pittsburgh, PA
Phone: (412) 692-2852

Dr. Bartlett has particular expertise in the management of advanced, complex abdominal malignancies. He also has a research interest in treating advanced carcinomas in the peritoneal cavity, including peritoneal mesothelioma.

Claire F. Verschraegen, MD

Director, Clinical Trial Office and Investigational Drug Program/Cancer Research and Treatment Center, University of New Mexico, Albuquerque, NM
Phone: (505) 272-4551

Dr. Verschraegen is currently conducting a front-line Alimta/gemcitabine trial for peritoneal mesothelioma patients. She also offers the following Phase I trials for patients who have already been treated with Alimta:

Phase I Study of Capecitabine with Cisplatin and Irinotecan in Patients with Advanced Malignancies
Phase I Study of Intravenous TZT-1027 and Gemcitabine, Administered on Day 1 and Day 8 of a Three Week Course in Patients with Advanced Solid Tumors
Phase I Study of Flavoperidol in Combination with Gemcitabine and Irinotecan in Patients with Metastatic Cancer

Biography

David P. Mason, MD

Staff Surgeon, Department of Thoracic and Cardiovascular Surgery/Cleveland Clinic Foundation, Cleveland, OH
Phone: (216) 444-4053

Dr. Mason is a proponent of aggressive multimodality therapy for malignant mesothelioma. This includes extrapleural pneumonectomy, chemotherapy and radiation with Intensity Modulated Radiation Therapy (IMRT). Cleveland Clinic Foundation has a multidisciplinary Thoracic Oncology team with extensive experience and clinical trials in the management of malignant mesothelioma.

Biography

David M. Jablons, MD

Assistant Professor of Surgery Chief, General Thoracic Surgery/UCSF Mt. Zion Medical Center, San Francisco, CA
Phone: (415) 885-3882

Dr. Jablons treats pleural mesothelioma with a radical pleurectomy/decortication and is researching other therapies.

Biography

Lary A. Robinson, MD

Director, Division of Cardiovascular and Thoracic Surgery Principal Thoracic Surgical Oncologist/H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
Phone: (813) 972-8412

Dr. Robinson is a member of the multidisciplinary thoracic oncology group at H. Lee Moffitt Cancer Center which evaluates and treats all stages of mesothelioma. He is also involved in clinical research programs for lung cancer and mesothelioma.

Biography

Craig W. Stevens, MD, PhD

Division Chief, Radiation Oncology/H. Lee Moffitt Cancer Center & Research Institute/Tampa, FL
Phone: (813) 972-8424

Biography

Robert N. Taub, MD

Professor of Clinical Medicine, Columbia University College of Physicians and Surgeons/New York Presbyterian Hospital, New York, NY
Phone: (212) 305-4076

Dr. Robert Taub is a medical oncologist who directs the Connective Tissue Oncology Program at the Herbert Irving Comprehensive Cancer Center, where there are a number of ongoing multimodality studies of patients with pleural and peritoneal mesothelioma. The Center is based at the Columbia University College of Physicians and Surgeons. Click here for a press release announcing a new multimodality study.

Biography

Daniel Sterman, MD

Assistant Professor, Department of Medicine/University of Pennsylvania Medical Center, Philadelphia, PA
Phone: (215) 614-0984

Dr. Sterman is the co-author of several informative articles on treatment and clinical trials for pleural mesothelioma.

Biography

Eric Vallieres, MD

Associate Professor of Surgery, Section of General Thoracic Surgery/University of Washington Medical Center, Seattle, WA
Phone: (206) 598-4477

Dr. Vallieres uses a multidisciplinary approach to thoracic malignancies and related clinical trials. Please see Medical Journal & News Articles for an article Dr. Vallieres co-authored on Induction Chemotherapy, Extra Pleural Pneumonectomy And Adjuvant Fast Neutron Radiationtherapy For Pleural Mesothelioma (Dmm).

Biography

Stephen C. Yang, MD

Chief, Division of Thoracic Surgery/Associate Professor of Surgery and Oncology/Surgical Director, Lung Transplantation Program/Director, Thoracic Oncology Program/Johns Hopkins Medical Institutions, Baltimore, MD
Phone: (410) 614-3891

Biography

Mark J. Krasna, MD

Medical Director of the Cancer Institute at St. Joseph Medical Center/Towson, MD
Phone: (410) 427-2220

Dr. Krasna is the former Head of the Division of Thoracic Surgery, Professor of Surgery and Associate Director for Surgical Oncology in the Greenebaum Cancer Center at the University of Maryland Medical Center.

Dr. Krasna is a leader in the development of thoracic surgery. He is the author of the first textbook on thoracoscopic surgery and has instructed surgeons worldwide on his techniques.

Biography

David H. Harpole, Jr., MD

Associate Professor of Surgery, Thoracic Oncology Program/Assistant
Professor of Pathology, Duke University Medical Center, Durham, NC
Phone: (919) 668-8413

Biography

Harvey Pass, MD

Professor and Chief, Division of Thoracic Surgery and Thoracic Oncology, Department of Cardiothoracic Surgery/NYU School of Medicine and Comprehensive Cancer Center/New York, NY
Phone: (212) 263-7417

Gregory P. Kalemkerian, MD

Co-Director of Thoracic Oncology/University of Michigan Comprehensive Cancer Center/Ann Arbor, MI
Phone: (734) 936-5281

Dr. Kalemkerian directs the multidisciplinary thoracic oncology clinic at the University of Michigan Cancer Center, in addition to collaborating with the thoracic oncology team at Karmanos Cancer Institute, to develop novel clinical trials for mesothelioma patients.

Joseph S. Friedberg, MD

Chief of Thoracic Surgery/University of Pennsylvania at Presbyterian, Philadelphia, PA
Phone: (215) 662-9195

Dr. Friedberg is currently the Principal Investigator on a trial of photodynamic therapy for pleural malignancies, and also on a trial combining Alimta/cisplatin, surgery and XRT.

Robert Cameron, MD

UCLA Medical Center, Los Angeles, CA
Phone: (310) 794-7333

NEW MESOTHELIOMA TREATMENT APPROACHES

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New approaches to treat malignant mesothelioma are currently being tested. They often combine traditional treatments or include something entirely new. They include:

Angiogenesis and Anti-angiogenesis Drugs
Although progress has been made in the early detection of cancer, and in improved treatment options once cancer is diagnosed, there are still many cancers, including mesothelioma, which can not be cured and remain difficult to treat effectively. In recent years, researchers have learned a great deal about how cancer cells differ from normal cells and, in an effort to find drugs without the potentially severe side effects of chemotherapy, have now discovered drugs which target the tumor itself while sparing the body’s normal cells. One such group are the anti-angiogenesis drugs.

Learn more about anti-angiogenesis agents in the treatment of mesothelioma.
Immunotherapy, sometimes called biological therapy, uses the body's own immune system to protect itself against disease. Researchers have found that the immune system may be able to recognize the difference between healthy cells and cancer cells, and eliminate those that become cancerous. Immunotherapy is designed to repair, stimulate, or enhance the immune system's natural anticancer function.
Substances used in immunotherapy, called biological response modifiers (BRMs) alter the interaction between the body's immune defenses and cancer, thereby improving the body's ability to fight disease. Some BRMs, such as cytokines and antibodies, occur naturally in the body, however, it is now possible to make BRMs in the laboratory that can imitate or influence natural immune response agents. These BRMs may:
- Enhance the immune system to fight cancer cell growth.
- Eliminate, regulate, or suppress body responses that permit cancer growth.
- Make cancer cells more susceptible to destruction by the immune system.
- Alter cancer cell's growth patterns to behave like normal cells.
- Block or reverse the process that changes a normal cell into a cancer cell.
- Prevent a cancer cell from spreading to other sites.
Many BRMs are currently being used in cancer treatment, including interferons, interleukins, tumor necrosis factor, colony-stimulating factors, monoclonal antibodies, and cancer vaccines.

Note to Patients:

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Chemotherapy treatment should be a cooperative effort between you and your doctor. The interaction that takes place is important to your health. It will not only help you feel better, but will also address any potential problems with miscommunication.

It is necessary for your doctor to be aware of any side effects which may result from your chemotherapy treatment.
These may include:
- Fever of, or greater than 101 degrees
- Nausea or vomiting
- Diarrhea or constipation
- Fatigue
- Tingling or numbness in the fingers or toes
- Ringing in the ears
- Bruises or rashes
- Sores in the mouth or throat
Taking other medication of any kind can alter the effects of chemotherapy or cause undesirable interactions.
Be sure you report all over-the-counter and prescribed medicines to your doctor. Don’t take aspirin unless it has been approved by your doctor. Ask your pharmacist if aspirin is contained in any drugs you plan to purchase.
Take extra care with your daily health.
Try to maintain a stable weight by eating a healthy diet and drinking plenty of fluids. If your stomach is upset, ask your doctor for helpful hints or work with a nutritionist who can tailor a program to your needs. Brush your teeth after every meal, or if you can’t brush, rinse your mouth thoroughly with water.
Stay away from people who have colds or the flu. Chemotherapy can compromise your immune system and lower your resistance to germs. Make sure you keep appointments for blood work – these tests help your doctor monitor your health.

Be open about your feelings regarding your treatment.
It is normal to feel sad, angry or afraid, however, letting these emotions get out of control can be detrimental to your overall well-being. Seek out the help of family, friends, your doctor, a counselor or a support group.

RADIATION THERAPY

Radiation therapy, also called radiotherapy, treats cancer by using penetrating beams of high energy or streams of particles called radiation. In treating mesothelioma, radiation may be used aggressively in combination with surgery, or palliatively to control symptoms.

In an aggressive combined modality approach, radiation is used to attack microscopic or residual disease remaining in the chest cavity after extrapleural pnuemonectomy. An example of this is Intensity Modulated Radiation Therapy (IMRT), which uses x-rays of varying intensities in conjunction with computer generated images to deliver targeted radiation directly to cancer cells while reducing the amount of radiation to surrounding healthy tissue. More on Intensity Modulated Radiation Therapy (IMRT).

Used palliatively, radiation can help control metastases (spread) of the tumor along tracks left by invasive procedures such as thoracoscopy, needle biopsy and chest tube drainage, or to control disease symptoms, such as pain or shortness of breath.

CHEMOTHERAPY

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Chemotherapy is defined as the treatment of cancer using chemical substances. When cancer occurs, abnormal cells continue to divide uncontrolled. Anticancer, or chemotherapy drugs, work to destroy cancer cells by preventing them from multiplying. Read more on types of chemotherapy medicines.

Purposes of Chemotherapy

Chemotherapy may be used to achieve different goals, depending on the stage of the cancer at the time of diagnosis and the age and health of the patient. Since chemotherapy for mesothelioma is not considered "curative", the goal is:

To control the cancer by stopping its spread or slowing its growth.
To shrink tumors prior to other treatments, such as surgery. This is called neoadjuvant chemotherapy.
To destroy microscopic disease which may remain after surgery. This is called adjuvant chemotherapy.
To relieve symptoms, such as pain. This is called palliative chemotherapy, and is given in cases when a drastic reduction in the tumor is not expected.

The most common use for chemotherapy in mesothelioma patients, is as an option for those who are not surgical candidates, however, various cancer centers are now conducting trials using the neoadjuvant approach. Alimta (pemetrexed) is a drug approved by the Food and Drug Administration (FDA) for use with Cisplatin in the treatment of patients with malignant pleural mesothelioma whose disease is either unresectable or who are not candidates for curative surgery. Alimta is the first drug approval specific to mesothelioma.

The Alimta/Cisplatin chemotherapy regimen is the first Food and Drug Administration (FDA) approved treatment specifically for malignant pleural mesothelioma. This is currently considered the most effective first-line treatment for mesothelioma patients who are not surgical candidates. A multi-targeted antifolate drug, Alimta works by blocking the enzymes necessary for DNA copying and cell division. During the clinical trial process, Alimta/Cisplatin improved median survival for pleural mesothelioma patients by approximately three months over treatment with Cisplatin as a single agent. Eli Lilly's information on treatment with Alimta.

As with any medical treatment, it is important to discuss the use of Alimta with your doctor. This conversation should include all pertinent information regarding effectiveness, administration and possible side effects of the drug combination. It is also important to begin vitamin supplementation of B12 by injection during the week prior to treatment (to be repeated every 9 weeks), and folic acid by mouth daily (to be continued until 21 days after the last cycle of Alimta). Additionally, you will be given an oral steroid medication to minimize the risk of skin rash or other possible side effects. Your doctor will have information on the correct dosages of each medication. Be sure to tell your doctor of any other medications you are taking (including non-prescription drugs) so he may be aware of any adverse interactions.

Alimta/Cisplatin is administered to patients on an outpatient basis every 21 days. This cycle of treatment involves a 10-minute IV infusion of Alimta followed by a 2 hour infusion of Cisplatin. How many cycles of treatment you receive will be dependent on your response rate to the drug (regression of the tumor or halt to progression of the disease) and the side effects you might experience.

Side effects of Alimta/Cisplatin are mild to moderate for most mesothelioma patients, i.e., nausea, vomiting and fatigue, and can usually be managed by your doctor. For some patients, however, side effects may be debilitating, and may require a decrease in dosage or removal from the program. All potential side effects should be mentioned to your doctor. Never assume any complaint is minor.

Administration of Chemotherapy

The most common way to administer chemotherapy is intravenously, or through a vein. A thin needle is inserted into a vein in the hand or in the lower arm. Intravenous administration of drugs allows for rapid entry into the blood stream. Drugs may also be delivered via catheters and/or ports.

Catheters are soft, thin, flexible tubes placed into a large vein in the body. They remain in place for as long as they are needed.
The catheter may sometimes be attached to a port, a small round plastic or metal disc placed under the skin on the chest. Ports also remain in place for as long as necessary.

Intraperitoneal chemotherapy may also be delivered through a catheter or a port. The catheter is inserted through the abdominal wall. Chemotherapy drugs can then be infused directly into the abdominal cavity. Ports may also be placed under the skin of the abdominal wall and the catheter tunneled between the skin and muscle into the peritoneum.

Side Effects of Chemotherapy

Cancer cells grow and divide more rapidly than normal cells, but some normal cells also multiply quickly, particularly those in the digestive tract, reproduction system, and hair follicles. It is the damage done to normal cells that causes side effects. The type of side effects you might experience and how severe they are, depend on the type of chemotherapy you are receiving, the dosage given and how your own body reacts. Before beginning any chemotherapy treatment, you will be asked to sign a consent form. Before signing the form, be sure your doctor informs you of all the facts regarding the treatment he/she will be administering, including information about the particular drug or combination of drugs to be used, the possible risks or side effects (including nausea and vomiting and peripheral neuropathy), the number of treatments you will receive and how often, and whether it will be given during a hospital stay or on an outpatient basis. More on vomiting and nausea from chemotherapy. More on peripheral neuropathy. More on anti-nausea treatment for chemotherapy patients.

Click here if you are interested in learning more about chemotherapy for mesothelioma and the types of questions you should ask your doctor.

Chemotherapy Schedules

How often you will receive chemotherapy will be determined by your doctor, taking into consideration factors such as the stage of your cancer, the types of drugs you receive, the anticipated toxicities of the drugs and the time necessary for your body to recover from these toxicities. The doctor may also consider whether the goal of the chemotherapy is to control the growth of the cancer, or to ease symptoms associated with the disease.

In general, chemotherapy treatment is administered in "cycles" — a "cycle" being defined as a period of treatment followed by a period of rest. This cycle allows the cancer cells to be attacked by the drugs, and then allows the body's normal cells time to recover. The combination of drugs used, the length of time to administer the drugs, how often they should be repeated and the number of cycles recommended have been analyzed throughly in clinical trials. For mesothelioma patients, the "standard" treatment is a combination of Alimta and cisplatin, administered IV, with a 10 minute infusion of Alimta followed by two hours of cisplatin, given in 21 day cycles. Modifications to this schedule may be made according to what your doctor feels is appropriate in your particular case.

The number of treatment cycles, or the length of time between the beginning and end of chemotherapy may vary, however in general, 3 to 4 cycles of treatment are given before response is evaluated; 2 to 3 cycles are considered a minimum to assess for effectiveness. After response to the treatment has been determined, the following criteria will be used to decide whether chemotherapy should continue:

If there is shrinkage of the tumor, or the disease is kept stable, chemotherapy may be continued for as long as it can be tolerated and there is no disease progression.
If there is continued disease progression, chemotherapy will be stopped, and the patient will be given alternative options.

The goal of setting a chemotherapy schedule is to make treatment as effective, timely and trouble-free as possible, but while the drugs are working to kill cancer cells, they may also affect healthy cells causing side effects. One of the most common side effects, and one your doctor will monitor carefully, is a chemotherapy-induced low white blood cell count (neutropenia) which means your immune system is weakened, therefore leaving you more prone to infection. While this side effect is anticipated when someone is undergoing chemotherapy, it can cause delays in your treatment schedule, or changes in the dosage of the drugs you will receive. Click here for more on understanding your blood counts.

SURGERY

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Diagnostic Procedures

As previously mentioned in the "Symptoms" section of this website, a diagnosis of mesothelioma from fluid is many times inconclusive. Given this fact, diagnostic surgery becomes a necessary next step in confirming and staging mesothelioma.

Thoracoscopy enables a physician to evaluate the pleural cavity and to conduct multiple tissue biopsies under direct vision. In up to 98% of cases, a definitive diagnosis can be obtained. Often, chemical pleurodesis aimed at relieving the accumulation of fluid in the intrapleural space, can be accomplished during the same procedure. It is also possible to gauge the extent of the tumor, and make a determination of surgical resectability. While less invasive than an open biopsy, it can only be performed on patients where tumor has not obliterated the pleural space.

VATS, or video-assisted thoracic surgery is an alternative to thoracoscopy, although because of its more invasive nature, concerns of tumor seeding increase. By utilizing small incisions, the physician can view the pleural space with the assistance of a camera, and obtain sufficient tissue samples for analysis by a pathologist. Extent of the tumor (i.e., pleural involvement, chest wall invasion) may also determined, and recommendation as to the type of debulking procedure necessary can be made at this time.

Mediastinoscopy is sometimes used as an aid in staging extent of disease when enlarged nodes are seen using imaging techniques.

Laproscopy is used in mesothelioma patients in cases where imaging techniques suggest possible invasion of the tumor through the diaphragm. This information can be important in evaluating a patient for potential pleurectomy or extrapleural pneumonectomy.

Palliative Procedures

Palliative surgical procedures are those which treat a symptom of mesothelioma, without aggressively treating the disease itself.

Chest Tube Drainage and Pleurodesis is considered the most common of palliative treatments. Fluid build-up, or pleural effusion, is most often the first symptom which will prompt mesothelioma patients to seek medical attention. Once this effusion has occurred, it is many times persistent, returning rapidly after initial thoracentesis (draining of the fluid). In order to eliminate this problem, the pleural space must be closed. This is accomplished by use of a talc slurry or other sclerosing agent which produces an adhesion.

Thoracoscopy and Pleurodesis is done in conjunction with VATS using a powdered form of talc versus talc slurry. Both this and chest tube drainage and pleurodesis will be only effective if there is no tumor encasing the lung which restricts its expansion.

Pleuroperitoneal Shunt plays a limited role in palliation for several reasons. It involves placement of a catheter run under the skin from the pleural to the peritoneal cavity. Obstruction of the catheter and possible seeding of the tumor into the abdominal cavity may be concerns.

Pleurectomy, used as a palliative procedure, may be performed where more extensive surgery is not an option. In these cases, it is understood that all visible or gross tumor will not be removed. It is considered the most effective means of controlling pleural effusion in cases where the lung's expansion is restricted by disease.

Potentially Curative Procedures

These procedures are performed with "curative intent". Their goal is removal of all gross disease, with the knowledge that microscopic disease will most likely remain. Adjuvant therapy (another form of treatment in addition to the primary therapy) is typically aimed at eliminating residual disease.

For Pleural Mesothelioma:

Pleurectomy/Decortication is usually performed on patients with early stage disease (Stage I and selected Stage II), and attempts to remove all gross tumor. If it is found that all tumor can not be removed without removing the lung, this may be done at the same time and is called pneumonectomy.
Extrapleural Pneumonectomy is considerably more radical than other surgical approaches, and should be carried out by surgeons with great expertise in evaluating patients and performing the procedure itself. (See Finding Specialists.) Because in the past surgery alone has failed to effect a cure, or even to help prolong life for any extended period of time, it is currently being combined with traditional chemotherapy and/or radiation, or other new approaches such as gene therapy, immunotherapy or photodynamic therapy.

General Patient Selection Criteria for Extrapleural Pneumonectomy

Extrapleural pneumonectomy is a serious operation, and doctors experienced in this procedure choose their patients carefully. It is up to each individual surgeon to advise the patient on its feasibility and to conduct whatever tests he/she feel are necessary to optimize the patient's chances for survival and recovery. Following is a general list of patient selection criteria. This list may not be all inclusive, and may vary according to the preference of the surgeon.
- Karnofsky Performance Status score of >70. This score relates to what symptoms of disease the patient may be experiencing and how well they are able to conduct their daily activities. Some surgeons may require a higher performance status than others.
- Adequate renal (kidney) and liver function tests; no significant kidney or liver disease.
- Normal cardiac function per electrocardiogram and echocardiography.
- Adequate pulmonary function to tolerate the surgery.
- Disease limited to the ipsilateral hemithorax (the same side of the chest in which the mesothelioma is located) with no penetration of the diaphragm, extension to the heart or extensive involvement of the chest wall.
- Age of the patient is taken into consideration, but may not be as important as their overall status.
Surgeries of this nature should always be done with a complete understanding of the possible benefits and risks involved. If you are considering surgery as a treatment option, speak openly with your doctor about your concerns, and be sure all of your questions are answered to your satisfaction.

For Peritoneal Mesothelioma:

Cytoreductive Surgery is aimed at removing all or nearly all of the gross or visible tumor in the peritoneal cavity. In order to treat any remaining cancer cells, Intra-Peritoneal Hyperthermic (heated) Chemotherapy (IPHC) is then delivered to the abdominal cavity. The type of chemotherapy drug used may vary according to the physician’s preference. Click here for more on treatment of peritoneal mesothelioma.

MESOTHELIOMA TREATMENT OPTIONS

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The treatment program for mesothelioma depends on many factors, including: the stage of the cancer, where the cancer is, how far the cancer has spread, how the cancer cells look under the microscope and the patient’s age and desires.

TIME MATTERS

People diagnosed with this disease are often told the expected survival rate is only eight to twelve months. However, specialists in treating malignant mesothelioma at the leading cancer centers often have better statistics.

For instance, the five-year survival rate has approached 40% for selected patients of Dr. David Sugarbaker at Brigham and Women’s Center in Boston. To qualify for Dr. Sugarbaker’s treatment you must meet certain criteria. One of them is being in the early stages of the disease, so time is of the essence. To find out more about Dr. Sugarbaker and other physicians and cancer centers specializing in mesothelioma click on Finding Specialists.

Keeping track of your medical treatment is useful and a personal medical records file can help.

TRADITIONAL CARE

There are three traditional kinds of treatment for patients with malignant mesothelioma:

Surgery (taking out the cancer)
Chemotherapy (using drugs to fight the cancer)
Radiation Therapy (using high-dose x-rays or other high-energy rays to kill cancer cells)

Often two or more of these are combined in the course of treatment. (NEW! Click here for the newest trial of trimodal lung-sparing treatment for pleural mesothelioma: The Columbia Protocol.)

MESOMARK BLOOD TEST

In January 2007, the Food and Drug Administration (FDA) approved the MESOMARK assay to help monitor response to treatment in epithelial and bi-phasic malignant mesothelioma patients. A specific protein, or biomarker, called Soluble Mesothelin-Related Peptide (SMRP), may be released into the blood by mesothelioma cancer cells. By measuring the amount of SMRP in a blood sample, doctors may be able to better monitor a patient's progress. Based on the limited amount of data currently available, use of this test may be beneficial, but effectiveness has not been determined at this time. The MESOMARK blood test has NOT yet been approved for the early diagnosis of mesothelioma.

This test has been approved as a Humanitarian Use Device (HUD), meaning that physicians must follow certain procedures to qualify their patients for testing. Once the physician is certified, informational brochures will be sent to be distributed to each applicable patient.

Those wishing to take part in

MESOMARK testing will be asked to provide one or more samples of blood. The blood samples will then be sent to a national reference laboratory for testing. In conjunction with other clinical and laboratory data obtained by your doctor, decisions regarding your treatment and care may be simplified. You may discontinue testing at any time.

The costs associated with the MESOMARK blood test may not be covered under health insurance, therefore, you may be required to pay all or part of the costs out of pocket. It is recommended that you check with your insurance carrier to determine whether coverage is available under your policy.

MESOTHELIOMA DIAGNOSIS QUESTIONS

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Doctor-Patient Communication

An open line of communication between a patient and his or her physician is vital when dealing with a serious disease such as mesothelioma. There will be many questions regarding treatment, whether palliative or aggressive, choices to deal with, and life issues to confront. Being informed and proactive in your care will give you a sense of empowerment.

Although most physicians have limited time to spend with each patient at appointments, it is important to address issues as they occur and resolve them to the satisfaction of all parties involved. Initially, this may mean going to your appointment with a list of symptoms or concerns, or questions regarding specific tests that are recommended. Once mesothelioma has been diagnosed, you may have questions regarding treatment options.

Most questions from patients stem from an initial diagnosis of mesothelioma and subsequent treatment options. Following are some frequently asked questions regarding these two important issues.

What Is My Diagnosis?

There are three types of mesothelioma. Pleural mesothelioma is a cancer of the lining of the lung (pleura), peritoneal mesothelioma is a cancer of the lining of the abdominal cavity (peritoneum), and pericardial mesothelioma is a cancer of the lining surrounding the heart (pericardium). Sub-types (or cell types) of mesothelioma are epithelioid (the most common, and considered the most amenable to treatment), sarcomatous (a much more aggressive form), and biphasic or mixed (a combination of both of the other cell types).

The structural appearance of cells under the microscope determine the cell or sub-type of mesothelioma. Epithelioid is the least aggressive; sarcomatoid, the most aggressive. The biphasic or mixed cell type shows structural elements of both of the other two. More on the histologic subtypes of mesothelioma.

Epithelioid mesothelioma tissue

Sarcomatoid mesothelioma tissue

Biphasic mesothelioma tissue

MESOTHELIOMA STAGES

Treatment options are often determined by the stage of mesothelioma a patient is in. There are three staging systems currently in use for pleural mesothelioma and each one measures somewhat different variables; peritoneal mesothelioma is not staged.

Staging is the term used to describe the extent of a patient's cancer, based on the primary tumor and its spread in the body. It can help the medical team plan treatment, estimate prognosis and identify clinical trials for which the patient may be eligible.

Staging is based on a knowledge of how the cancer develops, from the primary tumor, to the invasion of nearby organs and tissues, to distant spread or metastasis. Staging systems have evolved over time, and they continue to change as scientists learn more about cancer. Some staging systems cover many different types of cancer, while others focus on more specific cancers. The TNM (primary tumor, regional lymph nodes, distant metastasis) is the most common staging system for mesothelioma.

Some elements common to most staging systems are:

Location of the primary tumor.
Size and number of the tumors.
Lymph node involvement.
Cell type and tumor grade.
Metastasis.

Many cancer registries, such as the National Cancer Institute's Surveillance, Epidemiology, and End Results Program (SEER) use summary staging, a system used for all types of cancer. Summary staging groups cancer into five main categories:

In situ - cancer that is present only in the layer of cells in which it began.
Localized - cancer that is limited to the organ in which it began with no evidence of spread.
Regional - cancer that has spread from the primary site to nearby lymph nodes or organs.
Distant - cancer that has spread from the primary site to distant lymph nodes or organs.
Unknown - cases where not enough information exists to indicate stage.

Several types of testing may be used to help doctors determine stage, and to formulate a treatment plan.

Physical examinations. The doctor examines the body by looking, feeling and listening to anything out of the ordinary.
Imaging techniques. Procedures such as x-rays, CT scans, MRIs and PET scans may show the location, size of the tumor and whether the cancer has spread.
Laboratory tests. Studies of blood, urine, fluid and tissue can provide information about the cancer. Tumor markers, sometime elevated when cancer is present, may provide information.
Pathology reports. Results of the examination of tissue samples can include information about the size of the tumor(s), extension into adjacent structures, type of cells and grade of the tumor. Results of the examination of cells in fluid, such as that from a mesothelioma-related pleural effusion, may also provide information.
Surgical reports. Observations about the size and appearance of the tumor(s), lymph nodes and nearby organs.

Staging information should be provided to the patient by his doctor so that potential treatment plans can be discussed. Stage of the mesothelioma, as well as consideration of other factors such as age, health status and the patient's wishes may dictate different treatment options.

The oldest staging system and the one most often used is the Butchart System which is based mainly on the extent of primary tumor mass and divides mesotheliomas into four stages. The more recent TNM system considers variables of tumor in mass and spread, lymph node involvement, and metastasis. The Brigham System is the latest system and stages mesothelioma according to resectability (the ability to surgically remove) and lymph node involvement.

Butchart System – extent of primary tumor mass

Stage I: Mesothelioma is present in the right or left pleura and may also involve the diaphragm on the same side.
Stage II: Mesothelioma invades the chest wall or involves the esophagus, heart, or pleura on both sides. Lymph nodes in the chest may also be involved.
Stage III: Mesothelioma has penetrated through the diaphragm into the lining of the abdominal cavity or peritoneum. Lymph nodes beyond those in the chest may also be involved.
Stage IV: There is evidence of metastasis or spread through the bloodstream to other organs.

TNM System -- variables of T (tumor), N (lymph nodes), M (metastasis)

Stage I: Mesothelioma involves right or left pleura and may also have spread to the lung, pericardium, or diaphragm on the same side. Lymph nodes are not involved.
Stage II: Mesothelioma has spread from the pleura on one side to nearby lymph nodes next to the lung on the same side. It may also have spread into the lung, pericardium, or diaphragm on the same side.
Stage III: Mesothelioma is now in the chest wall, muscle, ribs, heart, esophagus, or other organs in the chest on the same side with or without spread to lymph nodes on the same side as the primary tumor.
Stage IV: Mesothelioma has spread into the lymph nodes in the chest on the side opposite the primary tumor, or extends to the pleura or lung on the opposite side, or directly extends into organs in the abdominal cavity or neck. Any distant metastases is included in this stage.

Brigham System: (variables of tumor resectability and nodal status)

Stage I: Resectable mesothelioma and no lymph node involvement
Stage II: Resectable mesothelioma but with lymph node involvement
Stage III: Unresectable mesothelioma extending into chest wall, heart, or through diaphragm, peritoneum; with or without extrathoracic lymph node involvement
Stage IV: Distant metastatic disease

How Was This Diagnosis Determined, and How Accurate Were the Tests?

Although you probably took many different tests leading up to your diagnosis, a tissue biopsy is normally the final determining factor. Following are some tests your doctor may recommend, and what may or may not be concluded from these tests.

X-rays, CT scans, and MRIs - See the imaging section for more on these techniques. On conventional x-ray film, mesothelioma appears as a markedly thickened, nodular, irregular pleural-based mass which covers the pleural surface. The tumor often encompasses the involved lung, but is only rarely seen bilaterally. Chest wall, diaphragmatic, and mediastinal invasion may be seen in advanced cases. Moderate to large pleural effusion is often noted on the affected side. On CT scan, pleural thickening greater than 1 cm can be identified in over 90% of cases; thickening which extends into the interlobular fissure is seen in 85% of cases. Absence of pleural thickening does not preclude mesothelioma, and at times, the only CT finding is that of pleural effusion.
Cytology - Testing of the pleural fluid for malignant cells is considered to have limited value in diagnosing mesothelioma. Negative or inconclusive readings account for nearly 85% of all fluid tested. Even with a positive fluid report, many doctors prefer to perform a confirming tissue biopsy as long as it does not compromise the patient's health.
Needle Biopsy - In this test, done under local anesthetic, a large hollow needle is inserted through the skin and into the chest cavity. The needle is then rotated, and as it is taken out, tissue samples are collected. Because of the small sample size of the tissue, this type of biopsy is considered to be only 25-60% accurate in diagnosing mesothelioma. Because tumor seeding may occur along the needle tract in approximately 20% of patients, local radiation therapy may be used in conjunction with this test.
Open biopsy - This type of biopsy is considered to be the most accurate for mesothelioma diagnosis, and is the procedure of choice because it affords the pathologist a larger tissue sample.. It is done in a hospital under general anesthetic. As with a needle biopsy, local radiation may be used because of the possibility of tumor seeding.

Can I Be Treated by the Doctor Who Diagnosed My Mesothelioma?

If the doctor who diagnosed your mesothelioma is your primary physician, he will most likely refer you to a local oncologist for treatment. The oncologist may offer what he or she feels are the best treatment options, or, if their knowledge of this disease is limited, may suggest you seek out a doctor who specializes in mesothelioma. Most often these physicians are located at larger, teaching hospitals such as those listed in the Comprehensive Cancer Center Section. These facilities are ranked as state-of-the-art cancer centers, and are highly respected for their patient care and innovative cancer treatments. If your choice of treatment involves a radical surgical procedure or a clinical trial involving new, as yet unproven drugs, these facilities may be best for you. If your treatment involves an already-approved, standard form of chemotherapy, this can be carried out locally.

What Treatment Options Will I Be Offered?

Treatment options may vary according to the age and over-all health of the patient, and the extent of the disease. It is important to be informed of all available options for your particular case, so that you can make decision on the option you feel most comfortable with. Surgery, chemotherapy, and clinical trials, as well as new approaches such as photodynamic therapy, immunotherapy, and gene therapy may be offered. Speak openly with your doctor regarding suggested procedures. Questions may include:

Why is this procedure best for me?
What does the procedure entail?
What are the advantages/disadvantages of this treatment (i.e, will this procedure limit my eligibility for other treatments)?
What are the possible risks or adverse side effects?
What are the response, survival, and mortality rates associated with this procedure?

Is Palliative Treatment an Option?

In some circumstances, age, contributing health problems, or advanced disease may make aggressive treatment impossible. In these cases, palliative care (that which treats the symptoms, but not the disease itself) may be appropriate. If you opt for palliative care, it is doubly important to communicate fully with your doctor. Many symptoms of mesothelioma can be alleviated or substantially lessened if you are completely open with your doctor. Each time you have an appointment, tell your doctor how you feel, what discomfort you are experiencing, and your level of pain. A good doctor should be willing to address your questions and concerns.

MESOTHELIOMA DIAGNOSIS

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How is mesothelioma diagnosed?

A diagnosis of mesothelioma is most often obtained with careful assessment of clinical and radiological findings in addition to a confirming tissue biopsy. (Learn about typical mesothelioma symptoms.) A review of the patient's medical history, including history of asbestos exposure is taken, followed by a complete physical examination, x-rays of the chest or abdomen, and lung function tests. A CT scan or MRI may also be done at this time. If any of these preliminary tests prove suspicious for mesothelioma; a biopsy is necessary to confirm this diagnosis.

Imaging Techniques and Their Value in Diagnosing and Assessing Mesothelioma

There are several imaging techniques which may prove useful when mesothelioma is suspected due to the presence of pleural effusion combined with a history of occupational or secondary asbestos exposure. While these imaging techniques can be valuable in assessing the possibility of the cancer, definitive diagnosis is still most often established through fluid diagnosis or tissue biopsy.

Some of the most commonly used imaging methods include:

• X-ray

A chest x-ray can reveal pleural effusion (fluid build-up) which is confined to either the right (60%) or left (40%) lung. On occasion, a mass may be seen. Signs of prior non-cancerous asbestos disease, such as pleural plaques or pleural calcification, or scarring due to asbestosis may also be noted.

• Computed Tomography (CT)

CT scans are also able to define pleural effusion, as well as pleural thickening, pleural calcification, thickening of interlobular fissures, or possible chest wall invasion. CT, however, is not able to differentiate between changes associated with benign asbestos disease (pleural disease), or differentiate between adenocarcinoma of the lung wh

ich may have spread to the pleura verses mesothelioma. CT scans may also be valuable in guiding fine needle aspiration of pleural masses for tissue diagnosis.

• Magnetic Resonance Imaging (MRI)

MRI scans are most often used to determine the extent of tumor prior to aggressive treatment. Because they provide images in multiple planes, they are better able to identify tumors as opposed to normal structures. They are also more accurate than CT scans in assessing enlargement of the mediastinal lymph nodes (those lymph nodes which lie between the two lungs), as well as a clear diaphragmatic surface, both of which play an important role in surgical candidacy.

• Positron Emission Tomography (PET)

PET imaging is now becoming an important part of the diagnosis and evaluation of mesothelioma. While PET scans are more expensive than other types of imaging, and are not always covered under insurance, they are now considered to be the most diagnostic of tumor sites, as well as the most superior in determining the staging of mesothelioma. Further explanation of PET scans.

• CT/PET

For patients who may be candidates for aggressive multimodality treatment (surgery, chemotherapy and radiation), accurate clinical staging is extremely important. Integrated CT/PET imaging provides a relatively new tool in this respect, and has become the imaging technique of choice for determining surgical eligibility. By combining the benefits of CT and PET (anatomic and metabolic information) into a single scan, this technology can more accurately determine the stage of the cancer, and can help identify the best treatment option for the patient. Read about a study of CT-PET imaging in preoperative evaluation of patients with malignant pleural mesothelioma.

A needle biopsy of the mass, or the removal and examination of the fluid surrounding the lung, may be used for diagnosis, however, because these samples are sometimes inadequate as far as determining cell type (epithelial, sarcomatous, or mixed) or because of the unreliability of fluid diagnosis, open pleural biopsy may be recommended. In a pleural biopsy procedure, a surgeon will make a small incision through the chest wall and insert a thin, lighted tube called a thoracoscope into the chest between two ribs. He will then remove a sample of tissue to be reviewed under a microscope by a pathologist. In a peritoneal biopsy, the doctor makes a small incision in the abdomen and inserts a peritoneoscope into the abdominal cavity.

Once mesothelioma is suspected through imaging tests, it is confirmed by pathological examination. Tissue is removed, put under the microscope, and a pathologist makes a definitive diagnosis, and issues a pathology report. This is the end of a process that usually begins with symptoms that send most people to the doctor: a fluid build-up or pleural effusions, shortness of breath, pain in the chest, or pain or swelling in the abdomen. The doctor may order an x-ray or CT scan of the chest or abdomen. If further examination is warranted, the following tests may be done:

Video-Assisted Thoracoscopic Surgery (VATS)

Over the past decade, the use of video-assisted thoracic surgery (VATS) has become one of the most widely used tools in the diagnosis of mesothelioma. Biopsies of the pleural lining, nodules, masses and pleural fluid can now easily be obtained using this minimally invasive procedure, and other therapies such as pleurodesis (talc) for pleural effusions can be done concurrently.While the patient is under general anesthesia, several small incisions or “ports” are made through the chest wall. The surgeon then inserts a small camera, via a scope, into one incision, and other surgical instruments used to retrieve tissue samples into the other incisions. By looking at a video screen showing the camera images, the surgeon is able to complete whatever procedures are necessary

In many cases, this video-assisted technique is able to replace thoracotomy, which requires a much larger incision to gain access to the chest cavity, and because it is minimally invasive, the patient most often has less post-operative pain and a potentially shorter recovery period.

Thoracoscopy

For pleural mesothelioma the doctor may look inside the chest cavity with a special instrument called a thoracoscope. A cut will be made through the chest wall and the thoracoscope will be put into the chest between two ribs. This test is usually done in a hospital with a local anesthetic or painkiller.

If fluid has collected in your chest, your doctor may drain the fluid out of your body by putting a needle into your chest and use gentle suction to remove the fluid. This is called thoracentesis.

Peritoneoscopy

For peritoneal mesothelioma the doctor may also look inside the abdomen with a special tool called a peritoneoscope. The peritoneoscope is put into an opening made in the abdomen. This test is usually done in the hospital under a local anesthetic.

If fluid has collected in your abdomen, your doctor may drain the fluid out of your body by putting a needle into your abdomen and using gentle suction to remove the fluid. This process is called paracentesis.

Biopsy

If abnormal tissue is found, the doctor will need to cut out a small piece and have it looked at under a microscope. This is usually done during the thoracoscopy or peritoneoscopy, but can be done during surgery. More on needle biopsies.

Pathology and The Role of Pathologists in the Diagnostic Process

Pathology, or the scientific study of cells, tissue, or fluid taken from the body is an integral part of a mesothelioma diagnosis. Most hospitals have their own pathology labs staffed by board-certified pathologists and licensed technologists. The importance of pathological diagnosis can not be underestimated, since the course of treatment is dependent upon an accurate diagnosis.

To make a diagnosis, pathologists examine tissue under a microscope, and based on established criteria, make a determination of benign vs. malignant cells. (More on biopsy tissue processing.) Subsequently, the type of cancer is determined. Although most pathologists have a general expertise of various diseases, a small number acquire training in a subspecialty, such as mesothelioma. These are physicians who have received world-wide recognition as premier experts, and have achieved high acclaim for their research, published articles and abstracts, and teaching. For a list of expert pathologists in the field of mesothelioma diagnosis, please call the MW toll free at 1-877-367-6376 or fill in the form at the bottom of this page specifying your request.

Knowing the stage is a factor in helping the doctor form a treatment plan. Mesothelioma is considered localized if the cancer is confined to the pleura, or advanced if it has spread beyond the pleura to other parts of the body such as the lungs, chest wall, abdominal cavity, or lymph nodes.

Immunohistochemical Markers for Mesothelioma

A diagnosis of any specific type of cancer often means ruling out other cancers in the process. This is true in the case of mesothelioma, where the most common “differential diagnosis” is that of adenocarcinoma versus mesothelioma.

During the biopsy procedure, the surgeon removes tissue samples to be sent to the laboratory. In the lab, slides are produced and then viewed and analyzed by a pathologist. These tissue specimens arrive at the lab with a request form that details patient information and history along with a description of the site in the body from which the specimen was obtained. Each individual specimen is numbered for each patient.

The pathologist then does a “gross examination” which consists of describing the tissue, and then placing it in a plastic cassette. The cassettes are then placed in a fixative that preserves the tissue permanently. Once the tissue has been fixed, it is processed into a paraffin block that will allow the pathologist to slice off thin microscopic sections that will then be stained to determine the patient’s diagnosis.

Immunohistochemistry is defined as “a method of analyzing and identifying cell types based on the binding of antibodies to specific components of the cell”. It is this process that helps diagnose mesothelioma versus adenocarcinoma (or other types of cancer).

Early on, the “markers” which helped distinguish mesothelioma from adenocarcinoma were “negative markers”; those expressed in adenocarcinomas, but not in mesotheliomas. This made it more difficult to confirm a diagnosis, because pathologists were dealing with the absence of, rather than the presence of certain markers. Some of these markers, which are normally “positive” in an adenocarcinoma diagnosis and “negative” in a mesothelioma diagnosis, are carcinoembryonic antigen (CEA), CD 15 (LeuM1), epithelial glycoprotein (Bg8), tumor glycoprotein (BerEp4) and tumor glycoprotein (MOC-31).

In more recent years, “positive markers” expressed by mesotheliomas have come to the forefront. Some of the markers which are normally “positive” in mesotheliomas and “negative” in adenocarcincomas are calretinin, cytokeratin 5, HBME-1, mesothelin, N-cadherin, thrombomodulin, vimentin and Wilm’s tumor gene product (WT-1).

It is important to remember that while the above markers are commonly used to help diagnose the epithelial sub-type of mesothelioma, that they may also be expressed in other types of cancer, and may not necessarily apply to the bi-phasic or sarcomatoid sub-types of mesothelioma. Your doctor can always contact a more specialized lab if he/she feels your diagnosis is in any way inconclusive.

MESOTHELIOMA SYMPTOMS

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The early symptoms of mesothelioma are generally non-specific, and may lead to a delay in diagnosis. Sometimes resembling viral pneumonia, pleural mesothelioma patients may present with shortness of breath, chest pain and/or persistent cough; some patients show no symptoms at all. A chest x-ray may show a build-up of fluid or pleural effusion (discussed below). The right lung is affected 60% of the time, with involvement of both lungs being seen in approximately 5% of patients at the time of diagnosis. Less common symptoms of pleural mesothelioma include fever, night sweats and weight loss. Symptoms of peritoneal mesothelioma may include pain or swelling in the abdomen due to a build-up of fluid, nausea, weight loss, bowel obstruction, anemia or swelling of the feet.

PLEASE KEEP IN MIND THAT THESE SYMPTOMS MAY BE CAUSED BY MESOTHELIOMA OR BY OTHER LESS SERIOUS CONDITIONS. ONLY A DOCTOR CAN MAKE A DEFINITIVE DIAGNOSIS.

Information on the symptoms, diagnosis, staging, and treatment of peritoneal mesothelioma.

Information on the symptoms, diagnosis, staging, and treatment of pleural mesothelioma.

Pleural Effusion

One of the most common symptoms of mesothelioma is a pleural effusion, or an accumulation of fluid between the parietal pleura (the pleura covering the chest wall and diaphragm) and the visceral pleura (the pleura covering the lungs). Both of these membranes are covered with mesothelial cells which, under normal conditions, produce a small amount of fluid that acts as a lubricant between the chest wall and the lung. Any excess fluid is absorbed by blood and lymph vessels maintaining a balance. When too much fluid forms, the result is an effusion.

Types

Pleural effusion is broken down into two categories, transudates and exudates. A transudate is a clear fluid that forms not because the pleural surfaces are diseased, but because of an imbalance between the normal production and removal of the fluid. The most common cause of transudative fluid is congestive heart failure. An exudate, which is often cloudy and contains many cells and proteins, results from disease of the pleura itself, and is common to mesothelioma. To determine whether a fluid is a transudate or exudate, a diagnostic thoracentesis, in which a needle or catheter is used to obtain a fluid sample, may be conducted.

Symptoms

As the volume of fluid increases, shortness of breath, known as "dyspnea", and sometimes pain, ranging from mild to stabbing, may occur. Some patients may experience a dry cough. When the doctor listens to the patient’s chest with a stethoscope, normal breath sounds are muted, and tapping on the chest will reveal dull rather than hollow sounds.

Diagnosis

Diagnosis of pleural effusion is usually accomplished with a simple chest x-ray, although CT scans or ultrasound may also be used. A special x-ray technique, called a lateral decubitus film, may be used to detect smaller effusions or to enable the physician to estimate of the amount of fluid present. If the underlying cause of the effusion is readily apparent (such as in the case of severe congestive heart failure), sampling of the fluid may not be necessary, however, because pleural effusion may be symptomatic of a number of disease processes from benign to malignant, a fluid sample is generally taken. Diagnostic thoracentesis, in which cells are extracted from the pleural cavity, is commonly done when the possibility of mesothelioma exists, however, in up to 85% of cases, the fluid tests negative or inconclusive even though cancer is present. It is ultimately a needle biopsy of the pleura (lining of the lung) or an open surgical biopsy which confirms a mesothelioma diagnosis.

Treatment

Pleural effusion caused by heart failure or infection can usually be resolved by directing treatment at the cause, however, when testing has realized no diagnosis, and fluid continues to build or recur, doctors may recommend chest tube drainage and chemical pleurodesis. Chemical pleurodesis is a technique in which a sclerosing agent is used to abrade the pleural surfaces producing an adhesion between the parietal and visceral pleurae. This will prevent further effusion by eliminating the pleural space. Talc appears to be the most effective agent for pleurodesis, with a success rate of nearly 95%. It is highly effective when administered by either poudrage or slurry. Poudrage is the most widely used method of instilling talc into the pleural space. Before spraying the talc, the medical team removes all pleural fluid to completely collapse the lung. After the talc is administered, they inspect the pleural cavity to be sure the talc has been evenly distributed over the pleural surface. Some doctors prefer to use talc mixed with saline solution which forms a wet slurry that can roll around the pleural cavity.

MESOTHELIOMA'S CAUSE - ASBESTOS EXPOSURE

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At some point in our lives, nearly all of us have been exposed to asbestos in the air we breathe and the water we drink; from natural deposits in the earth, and from the deterioration of asbestos products around us. Most of us, however, do not become ill as a result of our exposure. More commonly, those who at some point are diagnosed with asbestos disease, have worked in jobs where more substantial exposure occurred over longer periods of time. Nevertheless, cases of mesothelioma have been documented as the result of lesser exposure, affecting family members of workers who came into contact with asbestos and brought it home on their clothing, skin or hair, or affecting those who lived in close proximity to asbestos manufacturing facilities. Symptoms of asbestos disease usually are not be apparent until decades after exposure.

Asbestos was used commercially in North America as early as the late 1800s, but its use increased dramatically during the World War II era when shipyards produced massive numbers of ships for the war effort. Since that time, asbestos-containing products were used by the construction and building trades, the automotive industry and the manufacturing industry. All told, more than 5,000 products contained asbestos.

For more than 50 years, products containing asbestos remained unregulated, and the manufacturers of those products continued to prosper, knowing full well that many of the millions of workers who came into contact with their products would ultimately suffer as the result of their actions. Finally, in the late 1970s, the Consumer Products Safety Commission banned the use of asbestos in wallboard patching compounds and artificial ash for gas fireplaces because the fiber could easily be released during use. In 1989, the Environmental Protection Agency banned all new use of asbestos, but uses established prior to that time were still allowed. Although awareness of the dangers of asbestos and public concern over the issue have led to a decline in domestic consumption over the years, a total ban on asbestos has not come to fruition. Asbestos is still imported, still used and still dangerous.

Although it is suggested that the number of mesothelioma cases in the U.S. has reached its peak and has begun to drop, a forecast released by the National Cancer Institute's Surveillance, Epidemiology, and End Results Program (SEER), in April, 2003, projected the total number of American male mesothelioma cases from 2003-2054 to be approximately 71,000. This number, however, does not take into consideration events such as the World Trade Center disaster on September 11, 2001, when millions of New Yorkers were potentially exposed to air filled with carcinogenic asbestos particles. When the latency period for asbestos disease is factored in, cases of mesothelioma will continue to be diagnosed for years to come. See our page on mesothelioma risk factors.

MESOTHELIOMA COMMON QUESTIONS

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What is Mesothelioma?
The National Cancer Institute states that: "Malignant mesothelioma, a rare form of cancer, is a disease in which cancer (malignant) cells are found in the sac lining the chest (the pleura), the lining of the abdominal cavity (the peritoneum) or the lining around the heart (the pericardium)."

What is peritoneal mesothelioma?
Peritoneal mesothelioma is a cancer of the lining of the abdominal cavity. This form of cancer makes up approximately one-fifth to one-third of the total number of mesothelioma cases diagnosed. More on peritoneal mesothelioma.

How do you get Mesothelioma?
Most people with malignant mesothelioma have worked on jobs where they breathed asbestos. Others have been exposed to asbestos in a household environment, often without knowing it. More about the different ways in which people have been exposed to asbestos.

How much exposure does it take to get the disease?
An exposure of as little as one or two months can result in mesothelioma 30 or 40 years later. Mesothelioma cause.

How long does it take after exposure for the disease to show up?
People exposed in the 1940s, 50s, 60s, and 70s are now being diagnosed with mesothelioma because of the long latency period of asbestos disease.

What is the prognosis for mesothelioma?
Like most cancers, the prognosis for this disease often depends on how early it is diagnosed and how aggressively it is treated. Click on Treatment Options to find out more about traditional and new approaches.

Is there any promising research or are there promising drugs for mesothelioma?
Research is being conducted at various cancer centers all over the United States as well as by pharmaceutical companies. To find more about these studies, click on Clinical Trials. To read abstracts of the latest journal articles on mesothelioma research and to access these articles, click on Medical Journal Articles; or Mesothelioma News for news articles. A recent study of Alimta showed patients living much longer with Alitma than other chemotherapy drugs.

Where can I find information on living with mesothelioma?
Mesothelioma Aid is a good website for resource for families dealing with mesothelioma. It includes advice and referrals to other resources for coping with cancer, caregiving, financial challenges, and support groups. Alternatively, contact us here at Mesothelioma Web for help finding resouces for living with this disease.

What kinds of other resources are available for people with mesothelioma?
There are numerous cancer web sites, some specific to mesothelioma. Because they are often difficult to locate, we have listed some relevant medical sites under Leading Cancer Links. We are always on the lookout for more so check our site often.

Are new treatments for mesothelioma being studied?

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Yes. Because mesothelioma is very hard to control, the National Cancer Institute (NCI) is sponsoring clinical trials (research studies with people) that are designed to find new treatments and better ways to use current treatments. Before any new treatment can be recommended for general use, doctors conduct clinical trials to find out whether the treatment is safe for patients and effective against the disease. Participation in clinical trials is an important treatment option for many patients with mesothelioma.

People interested in taking part in a clinical trial should talk with their doctor. Information about clinical trials is available from the Cancer Information Service (CIS) (see below) at 1–800–4–CANCER. Information specialists at the CIS use PDQ®, NCI's cancer information database, to identify and provide detailed information about specific ongoing clinical trials. Patients also have the option of searching for clinical trials on their own. The clinical trials page on the NCI's Cancer.gov Web site, located at http://www.cancer.gov/clinicaltrials on the Internet, provides general information about clinical trials and links to PDQ.

How is mesothelioma diagnosed?

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Diagnosing mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient's medical history, including any history of asbestos exposure. A complete physical examination may be performed, including x-rays of the chest or abdomen and lung function tests. A CT (or CAT) scan or an MRI may also be useful. A CT scan is a series of detailed pictures of areas inside the body created by a computer linked to an x-ray machine. In an MRI, a powerful magnet linked to a computer is used to make detailed pictures of areas inside the body. These pictures are viewed on a monitor and can also be printed.

A biopsy is needed to confirm a diagnosis of mesothelioma. In a biopsy, a surgeon or a medical oncologist (a doctor who specializes in diagnosing and treating cancer) removes a sample of tissue for examination under a microscope by a pathologist. A biopsy may be done in different ways, depending on where the abnormal area is located. If the cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples. If the cancer is in the abdomen, the doctor may perform a peritoneoscopy. To obtain tissue for examination, the doctor makes a small opening in the abdomen and inserts a special instrument called a peritoneoscope into the abdominal cavity. If these procedures do not yield enough tissue, more extensive diagnostic surgery may be necessary.

If the diagnosis is mesothelioma, the doctor will want to learn the stage (or extent) of the disease. Staging involves more tests in a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Knowing the stage of the disease helps the doctor plan treatment.

Mesothelioma is described as localized if the cancer is found only on the membrane surface where it originated. It is classified as advanced if it has spread beyond the original membrane surface to other parts of the body, such as the lymph nodes, lungs, chest wall, or abdominal organs.

How is mesothelioma treated?

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Treatment for mesothelioma depends on the location of the cancer, the stage of the disease, and the patient's age and general health. Standard treatment options include surgery, radiation therapy, and chemotherapy. Sometimes, these treatments are combined.

Surgery is a common treatment for mesothelioma. The doctor may remove part of the lining of the chest or abdomen and some of the tissue around it. For cancer of the pleura (pleural mesothelioma), a lung may be removed in an operation called a pneumonectomy. Sometimes part of the diaphragm, the muscle below the lungs that helps with breathing, is also removed.

Radiation therapy, also called radiotherapy, involves the use of high-energy rays to kill cancer cells and shrink tumors. Radiation therapy affects the cancer cells only in the treated area. The radiation may come from a machine (external radiation) or from putting materials that produce radiation through thin plastic tubes into the area where the cancer cells are found (internal radiation therapy).

Chemotherapy is the use of anticancer drugs to kill cancer cells throughout the body. Most drugs used to treat mesothelioma are given by injection into a vein (intravenous, or IV). Doctors are also studying the effectiveness of putting chemotherapy directly into the chest or abdomen (intracavitary chemotherapy).

To relieve symptoms and control pain, the doctor may use a needle or a thin tube to drain fluid that has built up in the chest or abdomen. The procedure for removing fluid from the chest is called thoracentesis. Removal of fluid from the abdomen is called paracentesis. Drugs may be given through a tube in the chest to prevent more fluid from accumulating. Radiation therapy and surgery may also be helpful in relieving symptoms.

How is mesothelioma treated?

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Surgery is a common treatment for mesothelioma. The doctor may remove part of the lining of the chest or abdomen and some of the tissue around it. For cancer of the pleura (pleural mesothelioma), a lung may be removed in an operation called a pneumonectomy. Sometimes part of the diaphragm, the muscle below the lungs that helps with breathing, is also removed.

Radiation therapy, also called radiotherapy, involves the use of high-energy rays to kill cancer cells and shrink tumors. Radiation therapy affects the cancer cells only in the treated area. The radiation may come from a machine (external radiation) or from putting materials that produce radiation through thin plastic tubes into the area where the cancer cells are found (internal radiation therapy).

Chemotherapy is the use of anticancer drugs to kill cancer cells throughout the body. Most drugs used to treat mesothelioma are given by injection into a vein (intravenous, or IV). Doctors are also studying the effectiveness of putting chemotherapy directly into the chest or abdomen (intracavitary chemotherapy).

What are the risk factors for mesothelioma?

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Working with asbestos is the major risk factor for mesothelioma. A history of asbestos exposure at work is reported in about 70 percent to 80 percent of all cases. However, mesothelioma has been reported in some individuals without any known exposure to asbestos.

Asbestos is the name of a group of minerals that occur naturally as masses of strong, flexible fibers that can be separated into thin threads and woven. Asbestos has been widely used in many industrial products, including cement, brake linings, roof shingles, flooring products, textiles, and insulation. If tiny asbestos particles float in the air, especially during the manufacturing process, they may be inhaled or swallowed, and can cause serious health problems. In addition to mesothelioma, exposure to asbestos increases the risk of lung cancer, asbestosis (a noncancerous, chronic lung ailment), and other cancers, such as those of the larynx and kidney.

Smoking does not appear to increase the risk of mesothelioma. However, the combination of smoking and asbestos exposure significantly increases a person's risk of developing cancer of the air passageways in the lung.

Who is at increased risk for developing mesothelioma?

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Asbestos has been mined and used commercially since the late 1800s. Its use greatly increased during World War II. Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with asbestos exposure were not known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos mines and mills, producers of asbestos products, workers in the heating and construction industries, and other tradespeople. Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of asbestos exposure in the workplace. People who work with asbestos wear personal protective equipment to lower their risk of exposure.

The risk of asbestos-related disease increases with heavier exposure to asbestos and longer exposure time. However, some individuals with only brief exposures have developed mesothelioma. On the other hand, not all workers who are heavily exposed develop asbestos-related diseases.

There is some evidence that family members and others living with asbestos workers have an increased risk of developing mesothelioma, and possibly other asbestos-related diseases. This risk may be the result of exposure to asbestos dust brought home on the clothing and hair of asbestos workers. To reduce the chance of exposing family members to asbestos fibers, asbestos workers are usually required to shower and change their clothing before leaving the workplace.

What is mesothelioma?

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Mesothelioma (cancer of the mesothelium) is a disease in which cells of the mesothelium become abnormal and divide without control or order. They can invade and damage nearby tissues and organs. Cancer cells can also metastasize (spread) from their original site to other parts of the body. Most cases of mesothelioma begin in the pleura or peritoneum.

What is mesothelioma?

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What is the mesothelium?

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The mesothelium is a membrane that covers and protects most of the internal organs of the body. It is composed of two layers of cells: One layer immediately surrounds the organ; the other forms a sac around it. The mesothelium produces a lubricating fluid that is released between these layers, allowing moving organs (such as the beating heart and the expanding and contracting lungs) to glide easily against adjacent structures.

The mesothelium has different names, depending on its location in the body. The peritoneum is the mesothelial tissue that covers most of the organs in the abdominal cavity. The pleura is the membrane that surrounds the lungs and lines the wall of the chest cavity. The pericardium covers and protects the heart. The mesothelial tissue surrounding the male internal reproductive organs is called the tunica vaginalis testis. The tunica serosa uteri covers the internal reproductive organs in women.

Mesothelioma

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Mesothelioma is a rare form of cancer in which malignant (cancerous) cells are found in the mesothelium, a protective sac that covers most of the body's internal organs. Most people who develop mesothelioma have worked on jobs where they inhaled asbestos particles.