Mesothelioma Treatment

There are three traditional treatment modalities for mesothelioma: – Surgery, Radiation Therapy and Chemotherapy. The location and the stage of the disease, as well as the patient’s age and general health, will determine which treatment should be used to get the best results. These treatments may also be combined. The multi-treatment approach appears to provide the most positive results for treating mesothelioma.

Statistically, the treatment of malignant mesothelioma using conventional therapies in combination with radiation and or chemotherapy on stage 1 or 2 mesothelioma have proved on average almost 75 percent successful in extending the patients life span by five years or more – this is commonly known as remission, -however this percentage may increase or decrease depending on date of discovery and therefore the stage of malignant development.

In January 2009, the United States FDA approved using conventional therapies such as surgery in combination with radiation and or chemotherapy on stage 1 or 2 mesothelioma after research conducted by a nationwide study by Duke University concluded an almost 50 point increase in remission rates.

Surgery
Surgery is a common treatment for mesothelioma, although by itself, has proved disappointing. However, research indicates varied success when used in combination with radiation and chemotherapy (Duke, 2008) A pleurectomy / decortication is the most common surgery, in which the Doctor may remove part of the lining of the chest or abdomen and some of the tissue around it. Less common is an extrapleural pneumonectomy (EPP), in which the lung, lining of the inside of the chest, the hemi-diaphragm and the pericardium are removed for the more advanced stages of the disease. Sometimes part of the diaphragm, the muscle below the lungs that helps with breathing, is also removed.

Radiation
Radiation therapy, also called radiotherapy, involves the use of high-energy rays to kill cancer cells and shrink tumours. 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). As part of a curative approach to mesothelioma, radiotherapy is also commonly applied to the sites of chest drain insertion, in order to prevent growth of the tumour along the track in the chest wall. Although mesothelioma is generally resistant to curative treatment with radiotherapy alone, palliative treatment regimens are sometimes used to relieve symptoms arising from tumour growth, such as obstruction of a major blood vessel. Radiation therapy when given alone with curative intent has never been shown to improve survival from mesothelioma. The necessary radiation dose to treat mesothelioma that has not been surgically removed would be very toxic.

For patients with localized disease, and who can tolerate a radical surgery, radiation is often given post-operatively as a consolidative treatment. The entire hemi-thorax is treated with radiation therapy, often given concurrently with chemotherapy. This approach of using surgery followed by radiation with chemotherapy has been pioneered by the Thoracic Oncology Team at Brigham & Women’s Hospital in Boston. Delivering radiation and chemotherapy after a radical surgery has led to extended life expectancy in some cases, with some patients surviving more than 5 years.

 
Chemotherapy
Finally, chemotherapy a systemic treatment modality, 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 (known as intravenous, or IV). Doctors are also studying the effectiveness of intracavitary chemotherapy -direct injection into the chest or abdomen

Chemotherapy is the only treatment for mesothelioma that has been proven to improve survival in randomised and controlled trials. The landmark study published in 2003 by Vogelzang and colleagues compared cisplatin chemotherapy alone with a combination of cisplatin and pemetrexed (brand name Alimta) chemotherapy) in patients who had not received chemotherapy for malignant pleural mesothelioma previously and were not candidates for more aggressive “curative” surgery. This trial was the first to report a survival advantage from chemotherapy in malignant pleural mesothelioma, showing a statistically significant improvement in median survival from 10 months in the patients treated with cisplatin alone to 13.3 months in the combination pemetrexed group in patients who received supplementation with folate and vitamin B12. Vitamin supplementation was given to most patients in the trial and pemetrexed related side effects were significantly less in patients receiving pemetrexed when they also received daily oral folate 500mcg and intramuscular vitamin B12 1000mcg every 9 weeks compared with patients receiving pemetrexed without vitamin supplementation. The objective response rate increased from 20% in the cisplatin group to 46% in the combination pemetrexed group. Some side effects such as nausea and vomiting, stomatitis, and diarrhoea were more common in the combination pemetrexed group but only affected a minority of patients and overall the combination of pemetrexed and cisplatin was well tolerated when patients received vitamin supplementation; both quality of life and lung function tests improved in the combination pemetrexed group. In February 2004, the United States Food and Drug Administration approved pemetrexed for treatment of malignant pleural mesothelioma. However, there are still unanswered questions about the optimal use of chemotherapy, including when to start treatment, and the optimal number of cycles to give.

These are the main treatment methods, however, Physicians are currently studying other treatment modalities, such as immunotherapy and intra-operative photodynamic therapy.

Immunotherapy
Treatment regimens involving immunotherapy have yielded variable results. For example, intrapleural inoculation of éBacillus Calmette-Gurin (BCG) in an attempt to boost the immune response, was found to be of no benefit to the patient (while it may benefit patients with bladder cancer). Mesothelioma cells proved susceptible to invitro lysis by LAK cells following activation by interleukin-2 (IL-2), but patients undergoing this particular therapy experienced major side effects. This trial was suspended in view of the unacceptably high levels of IL-2 toxicity and the severity of side effects such as fever and cachexia. Nonetheless, other trials involving interferon alpha have proved more encouraging with 20% of patients experiencing a greater than 50% reduction in tumour mass combined with minimal side effects.

Heated Intraoperative Intraperitoneal Chemotherapy
A procedure known as heated intraoperative intraperitoneal chemotherapy was developed by Paul Sugarbaker at the Washington Cancer Institute. The surgeon removes as much of the tumour as possible followed by the direct administration of a chemotherapy agent, heated to between 40 and 48°C, in the abdomen. The fluid is perfused for 60 to 120 minutes and then drained.

This technique permits the administration of high concentrations of selected drugs into the abdominal and pelvic surfaces. Heating the chemotherapy treatment increases the penetration of the drugs into tissues. Also, heating itself damages the malignant cells more than the normal cells.

Various other programs are also exhibiting favorable results. However, despite such successes, no cure for mesothelioma currently exists.

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