Mesothelioma treatment options
We offer the full range of diagnostic procedures and therapies, we also specialise in pain management and nutrition. We have access to clinical trials providing access to new drugs through the HCA / Sarah Cannon Centre with state of the art imaging facilities, modern and comfortable rooms, a new intensive care unit and state of the art chemotherapy and radiotherapy facilities through our partner HCA hospitals, we offer the best and most advanced treatments.
Is there a cure?
There is no known cure for mesothelioma, but some treatments can improve symptoms and prolong life significantly. Research in the field is progressing and new drugs become available regularly as part of clinical trials.
Surgery plays an essential role in establishing a diagnosis of mesothelioma, staging the cancer, and may play an essential part in multi-modality therapy in combination with chemotherapy, immunotherapy, and radiotherapy.
Mesothelioma is considered a chemo-resistant tumour. Thus, most mesothelioma cells have deficient molecular machinery, allowing them to survive chemotherapy. The best chemotherapy combinations for mesothelioma treatment seem to be with drugs belonging to the anti-folate family (pemetrexed and raltitrexed) with a platinum salt (cisplatin or carboplatin). Approximately 4 out of 10 patients respond to chemotherapy. Other chemotherapy drugs are commonly used in mesothelioma such as gemcitabine, vinorelbin, irinotecan, doxorubicin. Those drugs can cause serious side effects and significantly impair a patient’s quality of life. Chemotherapy cannot cure mesothelioma, but it can prolong life by months or years. Patients can receive several courses of chemotherapy, depending upon tolerance and response to treatment. The same drug can be used in case of good response. Alternatively, another drug can be offered if the first drug proved inefficient. Chemotherapy can be used in combination with surgery and radiotherapy to treat mesothelioma – this type of treatment is referred to as multi-modality therapy.
Radiotherapy is often used in mesothelioma treatment. It can control severe pain due to invasion of bones (ribs or spine) by the tumour. Radiotherapy is often used to prevent the growth of a tumour in a needle tract or port site following a tumour biopsy. A large trial is currently taking place in the UK to confirm the usefulness of radiotherapy in this indication (PIT trial). Radiotherapy is sometimes used to prevent tumour relapse after surgical removal. In this case it is called adjuvant radiotherapy. Radiotherapy treatments usually last from a few days to a few weeks and patients do not have to be admitted into hospital for this.
Conventional radiotherapy can be used, but this will usually cause collateral damage to the lung (radiation pneumonitis), to the oesophagus (oesophagitis) and possibly to other surrounding organs / structures (liver, stomach, kidney, spinal cord). A few years ago, doctors introduced a new radiotherapy technique named IMRT for intensity-modulated radiotherapy. This technique allows for more doses to be delivered to the mesothelioma tumour and less to be delivered to the surrounding organs/structures. This technique is presently being evaluated in several studies, but at present there is no evidence that it does improve mesothelioma tumour control.
Immunotherapy is a form of treatment that aims at boosting the immune system to attack the mesothelioma tumour. It relies either on agents or drugs that will attack the tumour directly by targeting key signals on malignant mesothelioma cells, or on agents or drugs that will cause the patient's own immune system (patients cells or/and antibodies) to attack and destroy the tumour. Immunotherapy trials have been performed for more than five decades in mesothelioma treatment, with an injection of BCG directly into the tumour, to most sophisticated gene-therapy delivered directly inside the chest cavity to neutralise and destroy tumour cells. Although some experiences have been positive, it is fair to say that immunotherapy usually works in patients with early-stage mesothelioma, but provides a limited life expectancy. At present, doctors are trying to combine immunotherapy with chemotherapy, radiotherapy or surgery to maximise the therapeutic response, offering a prolonged disease-free period by trying to immunise the patient against the tumour (an effect similar to a vaccination against a virus). Recent experiences in mesothelioma patients have proven that it is possible to induce the formation of antibodies directed towards tumour antigens by patients receiving immunotherapy. The future will show if this is enough to contain the tumour durably.
Surgery can be offered in mesothelioma treatment to establish a diagnosis (pleural biopsy), drain the fluid accumulated in the chest cavity and prevent its re-accumulation (pleurodesis), appreciate the extent of the tumour (staging), or remove the tumour (radical surgery).
Major and minor surgeries
Minor diagnostic surgery for mesothelioma can be performed under local anaesthetic with some IV sedation; major surgery is always performed under general anaesthesia in a surgical theatre.
Minor surgery is usually performed by thoracic surgeons, but experienced chest physicians do perform medical thoracoscopy in specialist centres. Keyhole surgery (thoracoscopy or VATS) involves making one inch incisions over the rib cage and introducing a camera inside the chest to visualise the pleura, inspect the lung, diaphragm, oesophagus, heart and vessels. Pleural biopsies are taken under direct vision. If fluid has accumulated in the cavity (pleural effusion) it will be drained during the same procedure and sent for analysis (cytology). Often, the surgeon will perform a pleurodesis at the same time to prevent fluid re-accumulation: sterile talcum powder, iodine or chemotherapy agents can be injected into the chest cavity to cause inflammation and obliterate the space between the lung and the rib cage. Rarely, the pleura can be removed surgically to allow for a full expansion of the lung (pleurectomy).
Patients are usually admitted to hospital for a few days for a pleurodesis and can expect to make a full recovery within four weeks.
In cases where the lung is trapped by the mesothelioma tumour and no lung re-expansion can be obtained, the surgeon can place an indwelling catheter in the chest cavity, which can be used daily to withdraw fluid from the cavity and relieve breathlessness. Fluid withdrawal can be done at home, usually with the help of a nurse.
Over the years, 2 main surgical procedures have been used to remove malignant pleural mesothelioma: extrapleural pneumonectomy (EPP) and pleurectomy / decortication (P/D). Both procedures have been performed for 5 decades at expert centres.
EPP is a major procedure where the all pleural tumour is removed together with the all lung, hemi-diaphragm and percardium (sac around the heart). The operation takes four to eight hours and patients are usually in hospital for two weeks postoperatively. A minimum of six to eight weeks’ recuperation is required after EPP.
Pleurectomy / decortication (P/D) is an alternative procedure where all the tumour around the lung is removed, but where the lung is spared and the diaphragm is spared in the majority of cases. The procedure takes around 4-6 hours and is usually well tolerated. The hospital mortality and complication rate are much lower after P/D. This procedure can be combined with chemotherapy, before or after.