Surgery for mesothelioma
Surgery for some types of mesothelioma might be done to try to bring about a cure or to relieve symptoms. Surgery to relieve symptoms (called palliative surgery) is often done in cases where the tumor has already spread or when the patient is too sick to go through more involved surgery.
To attempt a cure, major surgery might be needed. This might be done if the patient is in good health (other than the cancer) and if it seems as if the tumor is only in one place. While surgery is not likely to cure the cancer, it might extend the patient's life.
But in most cases the cancer has spread to other places before it is found. So the role of surgery in treating this cancer is not clear. If your doctor recommends surgery, ask for more details about the operation and what the goal is.
Surgery for pleural mesothelioma
There are 2 types of surgery that could be used if you have mesothelioma in the linings of the lungs. One is a bigger operation that attempts to remove all or most of the cancer and some of the tissues around it. (This surgery is called an extrapleural pneumonectomy or EPP.) This is a complex operation and is done only by surgeons in large medical centers. You must be in good overall health with good lung function and no other serious illnesses in order to have this surgery.
The other type of surgery that may be used is called a pleurectomy/decortication or P/D. This smaller operation may be done to try to cure some cancers, but it is more often used to relieve symptoms in cases where the whole tumor cannot be removed. It can help control the build-up of fluid, improve breathing, and decrease pain caused by the cancer.
An even smaller surgery called debulking might be done to remove as much of the mesothelioma as possible.
New Blood Test May Help Diagnose Mesothelioma Earlier
Investigators in California are evaluating new technology that could eventually help diagnose mesotheliomawith a simple blood test.
Mesothelioma is a rare cancer caused by exposure to asbestos. It strikes about 2,500 people in the U.S. each year. But its rarity – and its tendency to mimic other lung-related diseases – can make mesothelioma hard to diagnose. In recent years, some mesothelioma centers have begun evaluating the DNA composition of suspected mesothelioma cells using a test called a DNA array.
Now, a group of researchers in California reports that a different type of evaluation – one that looks for abnormal sugars (glycans) in blood serum – may offer another diagnostic option for mesothelioma. Anti-glycan antibodies are produced by the immune system in response to certain malignancies and viral diseases. This unique cancer diagnostic approach uses a printed glycan array (PGA) test, similar to a DNA array, to measure the binding of these anti-glycan antibodies and compare them with the glycans on the array.
In this pilot study of the PGA biomarker test, researchers evaluated samples of blood serum from 50 patients with malignant mesothelioma and from 65 patients who had been exposed to asbestos but had no mesothelioma symptoms. Researchers hope the PGA biomarker tests will help with early detection, diagnosis and prognosis of mesothelioma as well as help identify new therapeutic targets.
The study conducted by the Department of Computer Science at San Diego State University and funded by the National Cancer Institute, lays out the procedures for data preprocessing, quality control, data analysis, evaluation and visualization of the new PGA biomarker platform. The PGA array was developed in collaboration with researchers at NYU Cancer Center and in Russia.
The current biochemical tests for diagnosing mesothelioma include immunohistocehmistry (IHC). These IHC tests look for specific antibodies such as CEA, calretinin, cytokeratin 5/6, thrombomodulin, and N-cadherin. The advantage of the anti-glycan tests over the IHC tests is that the former can be performed on blood serum while the latter require mesothelioma tumor cells.
Genes Key to Mesothelioma Chemotherapy Response
Research being performed in Eastern Europe may eventually help doctors around the world predict which mesotheliomapatients will respond best to a particular type of chemotherapy.
Mesothelioma is a fast-growing cancer triggered by exposure to asbestos. It is often treated with multiple modalities, including chemotherapy. As more is understood about the impact of genetics on medication response, chemotherapy for cancers like mesothelioma is moving away from a ‘one-size-fits-all’ approach to a more tailored approach based on individual cellular characteristics.
Now, a team of biochemists in Slovenia are studying genetically-linked responses to the chemotherapy drug gemcitabine, a nucleoside analog that some studies have found to be a promising alternative to the more conventional cisplatin-pemetrexed combination for mesothelioma. In a phase II trial involving 78 mesothelioma patients treated with gemcitabine, half showed a complete or partial response to the drug. But others had little or no response or experienced serious side effects. In four cases, the mesothelioma spread while the patient was on gemcitabine.
To determine why some mesothelioma cases respond well to gemcitabine and others do not, the Slovenian team tested the cells of another 107 mesothelioma patients treated with a gemcitabine-platinum mix. Cell samples were tested for 11 different polymorphisms or genetic anomalies as well as haplotypes (particular combinations of DNA sequencing) that might influence response to gemcitabine.
Of the different genetic arrangements studied, two had no influence on treatment outcomes, one appeared to significantly decrease overall survival probability, two decreased the odds of experiencing nausea and vomiting and others were associated with better or worse tumor responses.
In a summary of their results, the Slovenian team concluded that, polymorphisms and haplotypes do appear to influence the efficacy and toxicity of gemcitabine and “should be validated as potential markers for the prediction of clinical outcome in patients with malignant mesothelioma.”
If further studies support the findings, doctors may eventually be able to test for gemcitabine compatibility and take some of the guesswork out of mesothelioma treatment selection.
Surgery Provides Better Mesothelioma Diagnosis for Some Patients
For patients who can tolerate it, a Japanese research team says an operation to remove part of the chest lining may be the best way to diagnose early malignant pleural mesothelioma.
Pleural mesothelioma, a rare but aggressive cancer of the membrane encasing the lungs (pleura), is often difficult to diagnose. A buildup of fluid between the layers of the pleura, known as pleural effusion, is one of the first clinical signs of mesothelioma. For this reason, pleural effusion cytology is often one of the first diagnostic tests performed in suspected cases. Doctors draw off some of the pleural fluid and test it for evidence of cancer cells.
But researchers from the Department of Thoracic Surgery at Hyogo College of Medicine in Nishinomiya, Japan point out that this method has a level of sensitivity of only about 60 percent. In about half of all mesothelioma cases, they say, the initial pleural effusion cytology gives a false negative result, potentially delaying critical treatments. Instead of relying too heavily on the results of pleural effusion cytology, the Japanese doctors say more physicians should consider going a step further and performing a surgical biopsy whenever mesothelioma is suspected.
“One practical way to reduce the number of misdiagnosed malignant pleural mesothelioma is to encourage performing thoracoscopic pleural biopsy unless definitive diagnosis other than MPM is established,” they write in the International Journal of Clinical Oncology. The researchers concede, however, that even that method has its drawbacks. “There still remain a considerable number of patients with radiological/thoracoscopic malignant pleural mesothelioma who are misdiagnosed with nonspecific pleuritis after a complete investigation including thoracoscopic biopsies.”
For some of these mesothelioma patients, the research team says an even more extensive operation called a total parietal pleurectomy may be the best way of making a definitive mesothelioma diagnosis. They report performing diagnostic total parietal pleurectomy in “highly selected patients” who are suspected of have mesothelioma. These are characterized as patients with strong clinical suspicion of mesothelioma, positive pleural effusion cytology but uncertain tissue biopsy results.
During a total parietal pleurectomy, the surgeon removes the outside or parietal layer of the pleura. Because of the risk of the operation, particularly for patients in fragile overall health, some other studies have cautioned against using the approach for diagnostic purposes. The Japanese doctors require their patients to sign an informed consent form for this “highly invasive diagnostic surgery”, but contend that, by providing a confirmed diagnosis earlier, it can be lifesaving for select patients.
Common Cold Virus – Uncommon Mesothelioma Treatment
Researchers at the University of Pennsylvania are fighting malignant mesotheliomawith an unexpected tool – the cold virus.
The approach fits into a category of treatment known as immunotherapy, which aims to harness the body’s own immune system to find and attack cancer cells. In the current study, Penn Medicine mesothelioma researchers, led by Steven Albelda, MD, and Daniel Sterman, MD, of the Pulmonary, Allergy, and Critical Care Division, injected mesothelioma patients with a modified form of the adenovirus – a virus normally associated with the common cold. The virus had been altered to express high levels of an immune system stimulant called Interferon-a, a protein that can boost the body’s ability to fight off viral infection.
Nine mesothelioma patients with varying stages of the disease received injections of the modified virus directly into their chest cavities. Almost all of them began producing anti-tumor antibodies. Although the four patients with the most advanced mesothelioma showed no signs of improvement, in the remaining five patients there was evidence of disease stability or even tumor regression. In one case that researchers described as “dramatic,” there was partial tumor regression at a site some distance away from the injection site. None of the patients experienced any major side effects from the treatment.
“Since there are very few effective treatments for advanced mesothelioma, it is important that we were able to demonstrate radiographic and biochemical evidence of clinical anti-tumor activity in some of our patients,” said Dr. Sterman, the study’s lead author, in a Penn Medicine press release. “The responses seen in this pilot study, albeit anecdotal, are notable as there are no proven second or third line agents for the treatment of malignant mesothelioma.”
Because of the long latency of mesothelioma, this research could have implications for thousands of people who were exposed to asbestos in the last 20 to 40 years. The new adenovirus immunotherapy approach is now being tested in combination with chemotherapy for early stage mesothelioma in an NIH-funded study at the University of Pennsylvania. Researchers worldwide are anxious to find a method of boosting the effectiveness of chemotherapy for mesothelioma.
Peritoneal Mesothelioma Survivors
There is a lot of depressing information on the internet about peritoneal mesothelioma and the survival associated with this cancer. Reading it you would think that no one has ever survived peritoneal mesothelioma beyond a year or so. This information is far from comprehensive. To help balance some of the negative information that is so prevalent on the Web, we present some case histories of long-term peritoneal mesothelioma survival as published in the peer reviewed medical literature.
9 Years +
In November 1979, a 73 year-old man had abdominal pain and distension and was found to have an abdominal mass. A laparotomy was performed that revealed peritoneal malignancy with ascites. A biopsy demonstrated that the tumor was malignant peritoneal mesothelioma. No special treatment was recommended other than draining of the ascites. In spite of the continuing ascites and the gradually-enlarging abdominal masses, the patient enjoys good health, and lives independently at home. How many more years (in excess of 9) this patient lived with peritoneal mesothelioma is not known.
See: Norman, P.E. and Whitaker, D., Nine-Year Survival in a Case of Untreated Peritoneal Mesothelioma, Med J Aust 1989; 150: 43-44.
15 Years +
A woman was diagnosed with peritoneal mesothelioma. She had surgery (“total excision”). Seven years later the peritoneal mesothelioma recurred and she had another surgery (“reexcision”). She remains well 15 years after the initial diagnosis. The patient did not receive chemotherapy.
See: Asensio, J.A., et al., Primary Malignant Peritoneal Mesothelioma: A Report of Seven Cases and a Review of the Literature, Arch Surg; Nov 1990, 125, 1477-1480.
17 + Years
In 1962, a 31 year-old woman had abdominal pain for several months and a mass was detected. She underwent exploratory laparotomy which found tumor nodules spread throughout her abdomen. The diagnosis of peritoneal mesothelioma was made. Complete surgical removal of the tumor was not possible. She was treated with radioactive phosphorus, radiation, and oral chemotherapy (cytoxan). She remained well for 17 years. In 1979 she had recurrent peritoneal mesothelioma. She was treated with cytoxan again and continued to live as of the writing of the published medical report.
Pleural Mesothelioma Survivors
There is a lot of depressing information on the internet about pleural mesothelioma and the survival associated with this cancer. Reading it you would think that no one has ever survived pleural mesothelioma beyond a year or so. This information is far from comprehensive and can be misleading. To help balance the negative information that is so prevalent on the Web, we present some case histories of long-term pleural mesothelioma survival as published in the peer reviewed medical literature. These pleural mesothelioma case histories are instructional in two ways: 1) they remind us that, like Paul Kraus, there are long term survivors of this cancer; 2) they allude to the importance that the immune system may play in mesothelioma.
12 Years +
In 1994, a 58 year old man complained of chest pain and shortness of breath. He had been exposed to asbestos previously through his work and was eventually diagnosed with malignant pleural mesothelioma. The patient decided not to have any active treatment at that time and continued with his life. Five years later he had an enlarging painless mass on his chest wall. A needle biopsy confirmed it was malignant. The patient had a left thoracotomy, multiple pleural biopsies, and chest wall resection. Pathology reconfirmed that the mass was malignant pleural mesothelioma. Seven years after the chest wall resection and 12 years after the initial diagnosis, the patient has no symptoms and no evidence of recurrence. No chemotherapy or radiation had been given.
The doctors who wrote up this case history for publication noted that there was “moderate host inflammatory response” and that “spontaneous regression may be an immune-mediated phenomenon.” In other words, the doctors hypothesized that the patient’s own immune system may have played a factor in his survival.
See: Pilling, J.E., et al., Prolonged Survival Due to Spontaneous Regression and Surgical Excision of Malignant Mesothelioma, Ann Thorac Surg, 2007; 83: 314-5.
14 Years
In 1986, a 65 year-old women had pain in her left chest wall. A chest X-ray revealed a small pleural effusion on this side. The patient declined an open biopsy and no diagnosis could be reached. She was treated for tuberculosis because of the high rate of this disease in her area. Her symptoms partially improved. In 1988 she had increasing pain over her chest. A biopsy was performed and malignant infiltration of the pleura was confirmed. She turned down treatment. In 1998, 10 years after the diagnosis of malignant pleural mesothelioma she had an enlarging mass over her left chest wall. Biopsy confirmed the diagnosis of pleural mesothelioma. She had a course of radiation and died in January 2000, 14 years after her initial symptoms.
The doctors who wrote this report counseled their colleagues that long-term survivors can occur with pleural mesothelioma and “one should not hold the belief that it is always the intervention that prolongs survival.” In other words, these doctors suggested that in some cases the intervention (i.e. chemo, radiation, surgery) may not be the factor that prolongs survival in pleural mesothelioma, but other factors may be at work.
See: Wong, C.F., et al., A Case of Malignant Pleural Mesothelioma with Unexpectantly Long Survival without Active Treatment, Respiration March/April 2002; 69, 2: 166-168.
7 Years +
In 1970, a 53 year-old man had shortness of breath and a sharp pain on his right side. An X-ray revealed a right side pleural effusion. The patient had worked at a plant adjacent to the Brooklyn Navy Yard from1955-1966 where asbestos had been used. In 1972 a thoracotomy was performed and a pleural biopsy was taken. The patient was diagnosed with malignant pleural mesothelioma. The patient never received any specific treatment for pleural mesothelioma. The report was written up in 1977 and apparently information about the continued life of this patient was not published after. We do not know how many more years or decades he lived.
The doctors noted in their discussion that, “This unusual course may be explained either by the presence of low-grade malignancy or by the unusual host resistance…Our findings are consistent with the concept that normal immunological function may effectively impede dissemination of the disease (malignant pleural mesothelioma).” In other words, these doctors are again alluding to how the immune system may play a role in managing pleural mesothelioma.
Maligmant-mesothelioma-survivors
Paul Kraus is not the only long-term survivor of malignant mesothelioma. There are others. We have heard about them and spoken to some over the years. What is fascinating is that many of these malignant mesothelioma survivors have something in common - they have all taken steps to improve or enhance their immune system. Some used alternative or complimentary therapies (with guidance from licensed clinicians) while others participated in clinical trials of immune therapy.
This raises the question - does the immune system play a role in controlling malignant mesothelioma? Paul Kraus' experience and those of other long-term malignant mesothelioma survivors suggests that such a role may be possible. In other sections of this website we present case histories of malignant mesothelioma survivors who were diagnosed with either pleural mesothelioma or peritoneal mesothelioma. In some of the pleural mesothelioma case histories, doctors discuss the role that the patient's immune system may have played in their extremely long survival.
In 1986, an article appeared in a medical journal that discussed this very issue of malignant mesothelioma and immunity.(1) This research focused on the immune responses of 118 healthy people compared to 20 patients with malignant mesothelioma and 375 long-term asbestos workers who were cancer-free. The researchers wanted to know if there were any measurable differences in the immune responses of the mesothelioma patients. Their findings demonstrated a relationship between the immune system and malignant mesothelioma. For example:
· The number of total T (T11+) and T-helper (T4+) cells were normal in asbestos workers with cancer, but were significantly reduced in patients with mesothelioma. T cells orchestrate, regulate and coordinate the overall immune response.
· Most patients with mesothelioma had a profound deficiency in Natural Killer cell (NK) activity which is suggestive of the role the immune system plays in the control of malignant mesothelioma. NK cells are a type of lethal lymphocyte that target tumor cells and protect against a wide variety of infectious microbes.
In the discussion section of the report, the researchers stated:
“These findings led us to speculate that biological phenomena generally categorized as chronic immunosuppression associated with the presence of asbestos fibers in the exposed workers may have caused the eventual breakdown of the host’s surveillance system and the onset of neoplasm [malignant mesothelioma].”
In other words, the researchers are suggesting that malignant mesothelioma may result from immune suppression. If this is true it would provide the biological basis for the role that the immune system and immune boosting approaches may play in the management of malignant mesothelioma.
Mesothelioma-Researching-Alternative-Treatments
When it comes to alternative therapies for cancer, the internet is a "mixed bag" filled with exaggerated claims, unreliable anecdotes, and some very credible reports. For the patient who has little time and who needs reliable information now, sorting through this can be a challenge. There is, however, one resource that is arguably better than many others. Medline is the National Library of Medicine's bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the health care system, and the preclinical sciences. Medline contains over 12 million citations and abstracts (summaries of research articles) from more than 4,800 biomedical journals published in the United States and 70 other countries. Medline is accessible from your computer via PubMed , which was developed by the National Center for Biotechnology Information (NCBI). Simply type www.pubmed.gov in your browser. Through Medline you can see what has been published about alternative cancer therapies by scientists and researchers. For anyone trying to make an informed treatment decision, these studies are worth browsing.
For example, certain herbs have been used throughout history for the treatment of various cancers. Because natural substances are difficult to patent, drug companies will not invest money to research and develop these substances. Nonetheless, you can find a handful of studies for almost any herb, vitamin or other substance you may be looking for. Although these studies are obviously not the final word, they do provide clues about the potential efficacy of these agents in cancer. While most of these studies are pre-clinical (in test-tubes, animal models), some are clinical (in patients). Faced with the hyperbole on the internet and the skepticism of most orthodox doctors, these studies can also be used to facilitate objective discussions with your physician.
There are three suggested steps to accessing this information:
- Go to Medline - www.pubmed.gov.
- Run a search by placing terms like the name of the herb or vitamin and cancer. For example, "red clover and breast cancer" or "vitamin c and prostate cancer" or "carrots and lung cancer." If nothing appears, try the Latin name.
- Understand what you are reading. While it is advantageous to read the entire article (often available in your local medical library), abstracts of the article are a good place to begin. And while, there are many considerations in assessing an article's reliability (i.e. journal, authors, conflicts of interest, size of study, etc.) for the purpose of getting started, you can begin by focusing on three key pieces of information:
1. What substance was tested?
You want to know what was actually tested. For example, some studies do not use the entire natural product, but only employ one or more chemical components that are isolated or synthesized. A problem with this approach is that all the components may have a synergistic effect and administering one ingredient may not be a fair test of what the agent can really do in patients.
2. Where was it tested?
There are many ways a test can be performed. For example, preclinical testing can be performed in cancer cell cultures (in vitro) which are cultures of cancer cells taken from a patient. Or, it can be performed in a cell line (a cancer cell culture that has been grown and used for years or decades). Or, it can be performed in animals (with animal cancers or human cancers). Or, the test can be performed clinically by administering the agent to actual cancer patients. Of course, the last one would be the most accurate representation of whether the agent works in people.
3. What was the outcome?
Here, you want to know what happened. Key terms to look for include apoptosis (this means the cancer cells committed cell suicide) anti-proliferation, and growth inhibition.
Some examples can be found below. (Please note that Cancer Monthly does not endorse the use of any of these substances for the treatment of your cancer, but encourages you to perform reliable research in order to make informed treatment decisions with your licensed healthcare provider).
Mesothelioma-Immunotherapies
Immunotherapies include vaccine therapy (i.e. autologous vaccines - vaccines made from the patient) or a treatment that includes an immune cytokine. These treatments typically attempt to stimulate an immune response in the patient's body to fight the cancer. Several of these approaches have been tried in treating mesothelioma.
Glossary
Autologous Vaccine is created when proteins from the patient's tumor cells are made into a vaccine that is designed to cause the patient's body to make antibodies against the tumor.
Immune Cytokine is a protein that is used by various white blood cells to communicate with each other. For example, some cytokines are used to promote inflammation near an infection.
Immune Response is how the body recognizes and defends itself against bacteria, viruses, and substances that appear foreign and harmful.
Immune System is made up of a network of cells, tissues, and organs that work together to protect the body. The cells that are part of this defense system are white blood cells or leukocytes. There are two basic types of leukocytes: (1) the phagocytes that consume invading organisms such as bacteria (the most common type is the neutrophil); (2) the lymphocytes that allow the body to remember and recognize previous invaders. There are two kinds of lymphocytes: B lymphocytes and T lymphocytes.