Mesothelioma Asbestos - Mesothelioma Surgery
Rusch229 reports a median survival of 10 months in her series of 50 EPPs, and the median survival of DMM patients having EPP (all histologies) in the National Cancer Institute (NCI) series is 9.4 months. The majority of patients were pathologic stage II or III in these two series. Most recently, Sugarbaker257a has reported a 17-month median survival in a series heavily weighted with stage I, epithelial patients (n = 52 of 183), using a multi-modality approach (see later) whose 2- and 5-year survivals were 68% and 46%, respectively. In the series by Rusch, the 2-year and 5-year survivals of stage I patients (n = 16 of 131) were 65% and 30%, respectively.
Surgery and Multi-modality Treatment. The Memorial Sloan- Kettering Cancer Center has been the leading institution for such technique, which includes as complete a parietal pleurectomy as possible to remove the bulk of the tumor followed by permanent (iodine 125, I125) or temporary (iridium 192, Ir192) implantation to deliver 3,000 cGy in 3 days to a 1-cm distance from the implant plane.126 Radioactive phosphorus 32 (P32) is selectively instilled intrapleurally 5 to 7 days after thoracotomy.
This is followed by external beam radiation therapy commencing 4 to 6 weeks postoperatively using electrons and photons to deliver 4,500 cGy in 4.5 weeks. In their series, there was minimum morbidity in the 41 patients discussed and median survival was 21 months at the time of their report. The majority of patients had recurrences at distant sites (54%), with or without local recurrence. Unfortunately, there has been little follow-up information with regard to the ongoing status of these patients, as the median follow-up in 40% of the patients was 12 months or less at the time of the first report in 1984.
Surgery has been part of various multi-modality therapies. There has been interest in combining debulking surgery with intracavitary treatment of pleural mesothelioma (see below). At the Dana Farber Cancer Institute, beginning in 1980, a multi-modality program has evolved consisting of EPP, followed by two cycles of paclitaxel and carboplatin. Concurrent radiation to a dose of 40.5 Gy is given with weekly paclitaxel.257a Over a 19-year period, 183 patients were treated with a perioperative mortality of 3.8%. The median survival in this group of patients is approximately 17 months, which is a significant improvement over other trials. Favorable subgroups include those with no mediastinal nodal involvement and epithelial histology.
A large nonrandomized series in Germany40b has also shown some prolongation of life expectancy with multi-modal treatment, compared with best supportive care. The treated patients, however, were younger, had a better performance status at presentation, and had no medical contraindications to surgery. These 93 patients chose either best supportive care or multi-modal treatment. Surgery consisted of pleurectomy- decortication or EPP, followed by systemic chemotherapy with Adriamycin, cytoxan, and vindesine. Patients in remission at the end of the chemotherapy (16 of the 57 accrued) received 45 to 60 Gy of radiation therapy to the hemithorax. Median survival was 13 months, compared with 7 months for those receiving best supportive care.
Photodynamic therapy involves the light activated sensitization of malignant cells.195d From July 1993 to June 1996, at the NCI, Bethesda, 63 patients with localized DMM were randomized to surgery, with or without intraoperative photodynamic therapy (PDT) directed at the pleural space. All patients received postoperative immunochemotherapy with cisplatin, tamoxifen, and interferon. There CHAPTER 89 / Malignant Mesothelioma 1301 Combining radiotherapy with concomitant chemotherapy using procarbazine, doxorubicin, or cyclophosphamide did not clearly improve response or survival (see Table 89.6), although, again, the lack of randomized trials precludes any firm conclusions.
The combined use of surgery (palliative pleurectomy) supplemented by brachytherapy of gross residual disease with I125, Ir192, or p32 followed by external radiation up to 4,500 cGy in 4.5 weeks has been evaluated at the Memorial Sloan-Kettering Cancer Center.176 Actuarial results in 41 cases, 17 of them still alive, showed an estimated median survival of 21 months and a projected 2-year survival of 40%.126 The median disease-free survival, however, was only 11 months. The use of local radioactive colloidal gold (198Au) in the treatment of pleural effusions has been summarized for a total of 18 cases of mesothelioma, with some long-term control of 3.5 to 11 years in a few of them.155 It is suitable only in early disease, since its penetration is, at most, 2 to 3 mm only.
In peritoneal mesothelioma, occasional long-term survivors have been described after radiotherapy. In one report, four cases were treated with intraperitoneal instillation of 10 mCi of 32P followed by 1,000 to 3,000 cGy to the entire abdomen in 3 to 4 weeks.220 An additional dose of 1,000 to 2,500 cGy was given to the pelvis in 2 to 3 weeks. Three patients also received chemotherapy (cyclophosphamide, with or without vincristine). Two of these patients survived more than 10 years. The local use of 198Au has been reported in 10 cases of peritoneal mesothelioma, with resolution of ascites lasting 2.5 to 51 years in some.155
Mesothelioma Diagnosis
A biopsy is needed to confirm a suspected case of mesothelioma asbestos. The procedure could be described as a type of diagnostic mesothelioma surgery necessary to stage and type a case of mesothelioma cancer.