Wirtten by: Prof.Dr. Semih Halezeroğlu
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What is Mesothelioma?
- It is malignant tumor of the pleura.
- It usually appears in people who have suffered long-term exposure to some substances called asbestos and erionite.
- In our country, especially in the Central Anatolia Region, a great number of mesothelioma patients have appeared as a result of the fact that the substance known as “white soil” that contains erionite is used to whitewash interior walls of houses.
- But many other patients do not suffer exposure to asbestos or erionite.
- And they are reported to have familial predisposition to this disease.
- After the ban on asbestos use in the industry, a significant decrease was observed in the incidence of the disease.
- Severe pains in the rib cage area, loss of weight, and coughing occur often in patients. Usually water collects in the thoracic cavity, and then shortness of breath may occur as a result of that water.
The following photo: Computed tomography and thoracoscopy images of the mesothelioma at the right side of our 52-year-old male patient.
How is Mesothelioma Diagnosed?
Story of the Patient, and the Symptoms of Mesothelioma
Mesothelioma is more common especially in our country’s regions called “white soil” regions. In addition, conditions arising in the pleura of those whose professions cause exposure to asbestos suggest the existence of mesothelioma.
There is no clinical examination findings specific to mesothelioma. The findings found are the ordinary findings found in all kinds of lung diseases: such as diminished breathing sounds on the affected side of the lung.
Radiologic Examinations and PET-CT
Normal chest X-rays are not adequate for the diagnosis of mesothelioma. Examination is necessarily made with more advanced methods when a suspected mesothelioma exists in the story of the patient and when a thickening or fluid is detected in the pleural by means of lung X-ray.
Computed Tomography and MRI
As seen in the photo below, thickening areas or fluid accumulation is detected in some places of the pleura through computed tomography. The red arrow in the photo indicates the areas with mesothelioma.
As for MRI, it is useful for providing a more detailed image of the condition of the tumor on the diaphragm and heart. If there is any doubt in the computed tomography in this respect, an MRI examination should be made, as well. Otherwise, MRI is not necessary.
Determination of the disease’s stage is of a critical importance, in terms of the selection of the appropriate treatment. Therefore, it is a necessity to make a detailed investigation before selecting the appropriate treatment.
In the adjacent MRI image, the mesothelioma was determined not to extend beyond the diaphragm.
In case of a suspected mesothelioma in a lesion, which appears in the pleura, PET-CT is performed to investigate whether that lesion consumes energy. If there is no energy consumption (involvement) in PET-CT, that lesion is extremely less likely to be a mesothelioma.
PET-CT is also important in terms of revealing whether mesothelioma has spread to other parts of the body.
No matter what treatment is used, the mesothelioma treatment should not be initiated without PET-CT.
In the adjacent photo, a mesothelioma is seen on the right side again. The arrow shows the high energy-consuming (involvement) areas in the PET-CT.
Taking fluid sample with a needle (thoracentesis) in case of the existence of fluid; and performing a needle biopsy or thoracoscopic biopsy to take a tissue sample from the tumor are the methods used in the diagnosis of malignant mesothelioma. Pathology examination should only diagnose the mesothelioma but also indicate its type.
What are the Treatment Methods for Malign Mesothelioma?
(The information here has been taken from the conclusion part of the International Mesothelioma Symposium held in Catania, Italy on 16 April 2015.)
- Chemotherapy is applied to a large proportion of patients.
- Among the drugs, Pemetrexed (Alimta) has made significant achievements. Successful results are obtained in patients, for whom this drug is used in combination with Cisplatin.
- Since chemotherapy has significant side effects, its detailed assessment should be made by the oncologist before its use.
- Chemotherapy regimen applied in such a way as to deliver heated chemotherapy drugs into the chest cavity has been applied for about 10 years. There is no significant achievement in the long-term results.
- Surgical treatment is used only for a certain type of mesothelioma (epithelial type) and at very early stages (in case of stage I and sometimes stage II).
- Radiotherapy is a method commonly used for certain organs such as the bone and brain, where the disease becomes metastatic. In some cases, radiotherapy can also be applied directly to mesothelioma. However, it should be kept in mind that the implementation of radiotherapy to a metastatic area may cause adverse outcomes; so, radiotherapy should be applied with a patient follow-up very meticulously.
- Methods called Cyberknife or IMRT put a smile on the faces, especially when used locally in the areas where the disease has recurred (in terms of reduction of the patient’s complaints).
The Cases Where Surgery Should be Performed for Mesothelioma
- There are scientific research studies showing that surgery prolongs the survival of patients when they have stage 1 mesothelioma (and some patients with stage 2 mesothelioma) and
- In cases where Mesothelioma is an Epithelial type disease. Therefore, surgery is recommended for this group of patients, as a selected group.
- Surgery is definitely harmful to a patient with sarcomatous or mixed type mesothelioma or
Stage III and Stage IV mesothelioma!
What do the International Sources Recommend?
What kinds of treatments should be applied to which patients are specified in this article. The information given above, as well as the mentioned chemotherapy, surgery and radiotherapy procedures, is similar to the information given in that article.
What are the Surgery Methods?
Surgical treatment consists of two main groups:
- Curative surgical intervention, i.e. an intervention intended for completely curing the disease.
- Palliative treatments, i.e. treatments intended for improving the patient’s quality of life and enabling him/her to breathe more easily during the disease.
1. Curative Surgical Treatment
Two different methods are used in this operation, as the removal of only the affected pleura, diaphragm and pericardium (Pleurectomy-Decortication) or also removal of the lung in addition to these (Extra Pleural Pneumonectomy).
In the past, removal of the lung was a common practice but today this method is less commonly used if there is no metastasis.
What method is required to be used is determined based on both preoperative examinations and findings obtained during the surgery.
The picture above shows the pleural tumor, pericardium and diaphragm that was surgically removed from our 61 year-old female patient.
The first image below (at the left) is the postoperative image of our patient’s chest cavity. The diaphragm was regenerated. In left-side surgeries, any material is not required to be put into the place of the removed pericardium. The other image shows a lung with mesothelioma that we surgically removed.
2. Palliative Surgical Treatment
- The liquid collected in the thoracic cavity of patients with mesothelioma should be discharged if it causes a severe shortness of breath.
- This process should be carried out with endoscopic (VATS) methods for all patients, whose general conditions are suitable, and the treatment intended for preventing the recurrence of the fluid accumulation should be applied during that process.
- After this process carried out with VATS, the fluid accumulation is extremely less likely to recur.
Video of Thoracoscopic Surgery for Mesothelioma
What are the Risks of Surgery?
- The risks of therapeutic pleurectomy/decortication operations are generally in the form of drainage with prolonged bleeding, air leakage from the lungs, increased heart rate, and arrhythmias (heart rhythm disorders). The average mortality (death) rate is 3%.
- In operations involving also the removal of the lung (Extra Pleural Pneumonectomy), a prolonged stay in intensive care unit is needed, unlike the above mentioned cases. In addition, the mortality rates are 6-7% and 3-4% for right-side surgeries and left-side surgeries, respectively. These rates that appear to be high are reduced with the measures taken. On the other hand, if we kept in mind that survival periods are expressed in months for inoperable mesothelioma patients, these rates would be understood to be at acceptable levels.
- But the risks are low in the process of VATS pleurodesis. The mortality rate is almost zero.
How Many Days Should I Stay in Hospital for Surgery?
The average required duration of stay in hospital is 5-6 days after curative surgeries, and 3 days after VATS pleurodesis.
Is Radiotherapy or Chemotherapy Needed after Surgery?
Chemotherapy is usually needed. Radiation therapy is not always needed. Decisions on treatment are made by our hospital’s oncology council, based on your postoperative pathology examination.