Treatment of Mesothelioma | Treatment options for mesothelioma patients

The Treatment of Mesothelioma

While there is no known cure for mesothelioma, there are treatment options that you can pursue to fight against this asbestos-related disease. This section gives you information about surgery, fluid removal, radiation therapy, chemotherapy, and ongoing clinical trials. Please see your doctor for the advisability of any or all of the treatments. This is solely supplied for informational purposes.

I. Malignant Pleural Mesothelioma
a. Surgery

i. Extrapleural pneumonectomy
- 1. Most aggressive procedure
- 2. Involves the removal of the visceral and parietal pleura (the membrane that surrounds the lungs and lines the wall of the chest cavity), lung, pericardium (membrane that covers and protects the heart), and part of the diaphragm ^2,5
ii. Pleurectomy/Decortication
- 1. Provides palliative relief, not considered curative
- 2. Involves removal of the visceral, parietal, and pericardial pleura from the top of the lung to the diaphragm, leaving the lung in place^2,5
iii. Video-assisted thoracoscopy with pleurodesis
- 1. Used to obtain tissue for diagnosis but at the same time allows for pleurodesis (irritation of the pleural space to result in its closing) to treat recurrent or symptomatic pleural effusions ⁵
- 2. Sclerosing agents that can be used include bleomycin, tetracycline, and talc. Talc is generally the least expensive.⁵

b. Radiotherapy

i. Primarily for palliative care ⁵
ii. Can be used to treat localized chest wall recurrences ²

c. Chemotherapy

i. Single agent
- 1. Includes doxorubicin, cisplatin, vinorelbine, gemcitabine, and et al. ^2,5
ii. Combination (still undergoing studies)
- 1. Platinum-based
  - a. Generally Cisplatin plus drug of alternative class ^2,5
  - b. Cisplatin plus pemetrexed ^2,5,7
i. Recently become regimen of interest and is being studied more
ii. It was found to be more effective compared to cisplatin alone in terms of median survival, time to disease progression, and response rate
iii. Given with vitamin supplementation to help control toxicities
- 2. Anthracycline-based ^2,5
  - a. Generally Doxorubicin plus drug of alternative class
  - b. Lower response rate than Platinum based

d. Combination therapy involving surgery, radiation, and chemotherapy still under study

II. Malignant Peritoneal Mesothelioma
a. Surgical Management

i. Cytoreductive surgery followed by peritonectomy
- 1. Surgery done first to remove and debulk tumors in preparation for chemotherapy to follow. ¹
- 2. Percentage of tumor that can be removed by surgical debulking directly affects final total response to chemotherapy. ¹
ii. Hyperthermic peritoneal perfusion with cisplatin and doxorubicin.
- 1. Hyperthermia has been shown to have direct tumoricidal activity and can enhance the cytotoxcity of chemotherapy. ¹
- 2. Side effects of treatments include bile leak, small bowel fistulas, and bleeding. Older patients have increased levels of these side effects. ¹

b. Medical Management

i. Single-agent general chemotherapy usually his less effective than combination chemotherapies. Cisplatin + pemetrexed is a new drug combination that has shown promise in pleural mesotheliomas and may also be effective in peritoneal mesothelioma. ¹

c. Ongoing Clinical Trials

i. Various new biomedical agents that target specific proteins on cancer cells are currently being tested for peritoneal mesothelioma. Among these are
- 1. ZD1839 (Iressa, AstraZeneca)
- 2. imatinib mesylate (Gleevec, Novartis)
- 3. bevacizumab (Avastin, Genentech)
ii. Cancer Gene Therapy
- 1. New therapy still under ongoing trials. Involves a Univ. of Penn group of doctors that developed a recombinant virus that recognizes specific proteins on cancer cells and destroys the cell. This has shown efficacy in labs and in animals. Clinical trials on human patients have shown that the treatment is well tolerated. They have seen a number of clinical responses including two long-term survivors who are more then 5 years from their initial therapy with no further treatment received. ¹

References:

1. Hassan R, Alexander R, Antman K, et al. Current treatment options and biology of peritoneal mesothelioma: meeting summary of the first NIH peritoneal mesothelioma conference. Ann Oncol. 2006; 17:1615-1619
2. Ismail-Khan R, Robinson LA, Willams Jr. CC, et al. Malignant Pleural Mesothelioma: A Comprehensive Review. Cancer Control. 2006; 13:255-263
3. National Cancer Institute : Malignant Mesothelioma Treatment (PDQ^®)Health Professional Version available at http://www.cancer.gov/cancertopics/pdq/treatment/malignantmesothelioma/healthprofessional
4. National Cancer Institute Fact Sheet: Mesothelioma: Questions and Answers available at http://www.cancer.gov/cancertopics/factsheet/sites-types/mesothelioma
5. Pistolesi M, Rusthoven J. Malignant Pleural Mesothelioma: Update, Current Management, and Newer Therapeutic Strategies. Chest. 2004; 126:1318-1329
6. Steele JPC, Klabatsa A. Chemotherapy options and new advances in malignant mesothelioma. Ann Oncol. 2005; 16:345-351
7. Vogelzang N, Rusthoven J, Symanowski J, et al. Phase III Study of Pemetrexed in Combination with Cisplatin versus Cisplatin Alone in Patients with Malignant Pleural Mesothelioma. J Clin Oncol. 2003; 21:2636-2644