Management of Malignant Pleural Mesothelioma
Section snippets
Mesothelioma: a global epidemic
Mesothelioma is characterized by a long latent period between exposure to the causative agent, usually asbestos, and subsequent tumor development: 96% have a latent period of more than 20 years [1]. This latency accounts for the delay in the peak incidence of mesothelioma deaths. The numbers of patients with mesothelioma are continuing to rise, despite the regulation of the use of asbestos in most developed countries since the 1980s.
In Europe, 5000 people die as a result of mesothelioma
Asbestos exposure
Greater than 80% of patients develop mesothelioma as a result of exposure to asbestos, which is usually occupational. Since the first report in 1960 from South Africa, numerous epidemiologic studies have confirmed the link between mesothelioma and asbestos exposure, and this knowledge has led to a ban in asbestos use in many countries [11]. Risk of mesothelioma is related to the duration and intensity of the exposure to asbestos (and the type of asbestos), with higher levels being associated
Pathology
The mesothelium consists of a monolayer of mesothelial cells, supported by submesothelial connective tissue [22]. In situ mesothelioma cells are 1 to 4 μm thick and are usually polygonal with a flattened appearance. There are tight gap junctions and desmosomes between mesothelial cells, and the cells seem to be able to synthesize and secrete inflammatory mediators and cytokines in response to stimuli. These are likely to have a key role in the modulation of inflammation in response to cell
Clinical picture
Mesothelioma symptoms are often insidious and nonspecific, which can lead to delay in presentation and in diagnosis. The mean time between symptom onset and diagnosis is 2 to 3 months, but 25% of patients may present more than 6 months after the onset of symptoms [46].
Prognosis
The prognosis of mesothelioma is poor, with an untreated median survival of approximately 9 months, although figures vary depending on the patient's selection group and how survival is calculated. A small proportion of mesothelioma patients follow a more indolent course, and prolonged survival (eg, >10 years), although rare, has been reported [53]. The Cancer and Leukemia Group B prognostic index identified poor performance status, age (>75 years old), chest pain, nonepithelioid histology,
Diagnosis
Definitive diagnosis of malignant mesothelioma is made histologically or cytologically. Although radiology is helpful, diagnosis based on clinical picture or radiology alone is inadequate.
Staging
Staging of mesothelioma is not easy to perform, and it is not justified or necessary in everyday clinical practice. Staging should be performed only if the patient is enrolled in clinical trials to categorize patients and to measure responses to treatment [48]. The necessary staging procedures should be governed by the study protocol.
Several staging classifications for mesothelioma have been suggested. The first, the Butchart classification, was devised in 1976, based on the experience of
Treatment
To date, there is no cure for mesothelioma. Malignant mesothelioma is difficult to treat and different from other malignant tumors for several reasons. It spreads along the serosal surface and infiltrates the underlying vital structures early, so surgery is unable to eradicate the tumor. It often arises from multiple sites on the parietal pleura and involves the visceral pleura early. Patients tend to present late in the clinical course because the symptoms are nonspecific and of gradual onset.
Summary
Malignant mesothelioma is increasing in incidence globally and has no known cure. Its unique clinical feature of local infiltration along tissue planes makes it a difficult neoplasm to manage. There have been few randomized controlled trials regarding treatment options, although these have increased in recent years, and results are eagerly awaited. Patient selection bias, variable inclusion methods, and different measurements of response and survival have hampered the interpretation of the
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Malignant pleural mesothelioma
2017, Medicina PaliativaPersistent lung expansion after pleural talc poudrage in non-surgically resected malignant pleural mesothelioma
2015, Annals of Thoracic SurgeryCitation Excerpt :In particular, pleurodesis in MPM effusions had generally lower success rates than in pleural fluid collection due to other malignancies [12, 13]. The lower success rate is probably related to the different pathobiology that characterizes metastatic pleural carcinomas from MPM [14]. The first difference is probably dependent from the life expectancy of MPM patients when compared with metastatic pleural carcinoma patients (12 vs 3 months, respectively).
Solution to case 26. Malignant pleural mesothelioma
2011, RadiologiaRespiratory Chest Pain: Diagnosis and Treatment
2010, Medical Clinics of North AmericaPleurodesis outcome in malignant pleural mesothelioma
2013, ThoraxCitation Excerpt :Conventional teaching suggests that malignant effusions should be drained and pleurodesis considered in symptomatic patients. However, MPM differs from metastatic pleural carcinomas in their pathobiology, which may explain the lower success rate of pleurodesis.1 First, pleurodesis failure increases progressively the longer the patient survives.