Review article
Malignant mesothelioma: options for management

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Staging

Staging of malignant mesothelioma is important for predicting survival and determining proper treatment. Unfortunately, until recently, there was no widely accepted staging system. Several groups have proposed staging systems, including Butchart [15], Chahinian [10], Sugarbaker [16], and the International Union against Cancer. These different systems are based on stage I–IV classifications or tumor node metastasis (TNM) staging. The most commonly used system in the past was that of Butchart,

Chemotherapy

Chemotherapy has limited efficacy in malignant mesothelioma. Over the past 45 years, scores of controlled studies, case reports, and retrospective analyses have compared single drug and combination therapies. Most of these have been small, single-institution trials of single agents or combination regimens [20], [21], [22]. In some reports, mesotheliomas have been included in phase II studies of sarcoma therapy. Consistently, the maximal response rate seen with any single chemotherapeutic agent

Radiation therapy

External radiation alone is unsuccessful in extending survival. There is modest regression of gross disease in many studies; however, no study has shown that survival is prolonged [24], [83], [84]. Laboratory studies show that mesothelioma is not radio-resistant; however, there are many reasons why pleural tumors are not conducive to radiation therapy.

Effective irradiation for mesothelioma requires enormous field sizes, essentially encompassing the entire hemithorax and mediastinum. Much can be

Surgery

Two surgical operations are important in the management of diffuse malignant mesothelioma: a debulking procedure (pleurectomy with or without decortication) and radical surgery (extrapleural pneumonectomy). One of the earliest attempts to resect a mesothelioma was made by Eiselberg in Germany in 1922, when an “endothelioma of the pleura” was removed from a 46-year-old man. He recommended radical surgery, but removed only the fourth through eighth ribs and a portion of the lung. An extrapleural

Results

Single-modality treatment—whether chemotherapy, radiation, or surgery—is believed to be of limited value in treating mesothelioma. Although there are numerous reports involving over 800 patients, it is difficult to assess the effect of surgical resection because of the diversity of the procedures [99], [100], [101]. Adjuvant therapies and combined modalities are being employed synergistically to improve efficacy, with some success [5], [102], [103], [104], [105], [106], [107], [108]. Bimodal

Emerging modalities

Regardless of the modality used, conventional forms of treatment for malignant mesothelioma have proven disappointing. Only 20% of tumors can be approached surgically, chemotherapy has limited results, and the neoplasm appears to be radioresistant. However, other modes of treatment are emerging, including immunotherapy, immunoconjugate therapy, and chemohyperthermia. In addition, gene therapy and photodynamic therapy provide even more sophisticated means of mesothelioma management [102], [131],

Palliative management

Palliative treatment is often the only help a thoracic surgeon can offer patients with mesothelioma. The two major symptoms addressed are pain and shortness of breath.

Once an effusion has developed, it is persistent and returns rapidly after simple drainage. Several liters may be removed in a matter of weeks [185]. Diuretics do not prevent reaccumulation. With repeat drainage, thickening of the pleura begins to occur, which in turn leads to difficulty in aspiration because of the development of

Summary

In the past, there has been a tendency to think of diffuse malignant pleural mesothelioma as one disease in therapeutic terms, regardless of histological type and tumor stage. This does not happen with other tumors, yet it is equally illogical and inappropriate in mesothelioma. As with other tumors, early diagnosis—while the disease is still in stage I, or even at an in situ stage—must be the goal so that therapy can be maximized, particularly if immunotherapy or gene therapy is to be used.

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