Advanced Malignant Mesothelioma (Stages II, III, and IV)

Standard treatment options:

  1. Symptomatic treatment to include drainage of effusions, chest tube pleurodesis, or thoracoscopic pleurodesis.[1]
  2. Palliative surgical resection in selected patients.[2,3]
  3. Palliative radiation therapy.[4,5]
  4. Single-agent chemotherapy. Partial responses have been reported with doxorubicin,epirubicin, mitomycin, cyclophosphamide, cisplatin, carboplatin, and ifosfamide.[68]
  5. Combination chemotherapy (under clinical evaluation).[6,7] Information about ongoing clinical trials is available from the NCI Cancer.gov Web site.
  6. Multimodality clinical trials.[913]
  7. Intracavitary therapy. Intrapleural or intraperitoneal administration of chemotherapeutic agents (e.g., cisplatin, mitomycin, and cytarabine) has been reported to produce transient reduction in the size of tumor masses and temporary control of effusions in small clinical studies.[1416] Additional studies are needed to define the role of intracavitary therapy.

References

  1. Boutin C, Viallat JR, Rey R: Thoracoscopy in Diagnosis, Prognosis and Treatment of Mesothelioma. In: Antman K, Aisner J, eds.: Asbestos-Related Malignancy. Orlando,Fla: Grune & Stratton, 1987, pp 301-21.  

  2. Butchart EG, Ashcroft T, Barnsley WC, et al.: The role of surgery in diffuse malignant mesothelioma of the pleura. Semin Oncol 8 (3): 321-8, 1981.  [PUBMED Abstract]

  3. Martini N, McCormack PM, Bains MS, et al.: Pleural mesothelioma. Ann Thorac Surg 43 (1): 113-20, 1987.  [PUBMED Abstract]

  4. Bissett D, Macbeth FR, Cram I: The role of palliative radiotherapy in malignant mesothelioma. Clin Oncol (R Coll Radiol) 3 (6): 315-7, 1991.  [PUBMED Abstract]

  5. Ball DL, Cruickshank DG: The treatment of malignant mesothelioma of the pleura: review of a 5-year experience, with special reference to radiotherapy. Am J Clin Oncol 13 (1): 4-9, 1990.  [PUBMED Abstract]

  6. Chahinian AP, Antman K, Goutsou M, et al.: Randomized phase II trial of cisplatin with mitomycin or doxorubicin for malignant mesothelioma by the Cancer and Leukemia Group B. J Clin Oncol 11 (8): 1559-65, 1993.  [PUBMED Abstract]

  7. Ong ST, Vogelzang NJ: Chemotherapy in malignant pleural mesothelioma. A review. J Clin Oncol 14 (3): 1007-17, 1996.  [PUBMED Abstract]

  8. Lerner HJ, Schoenfeld DA, Martin A, et al.: Malignant mesothelioma. The Eastern Cooperative Oncology Group (ECOG) experience. Cancer 52 (11): 1981-5, 1983.  [PUBMED Abstract]

  9. Mattson K, Holsti LR, Tammilehto L, et al.: Multimodality treatment programs for malignant pleural mesothelioma using high-dose hemithorax irradiation. Int J Radiat Oncol Biol Phys 24 (4): 643-50, 1992.  [PUBMED Abstract]

  10. Weissmann LB, Antman KH: Incidence, presentation and promising new treatments for malignant mesothelioma. Oncology (Huntingt) 3 (1): 67-72; discussion 73-4, 77, 1989.  [PUBMED Abstract]

  11. Vogelzang NJ: Malignant mesothelioma: diagnostic and management strategies for 1992. Semin Oncol 19 (4 Suppl 11): 64-71, 1992.  [PUBMED Abstract]

  12. Sugarbaker D, Harpole D, Healey E, et al.: Multimodality treatment of malignant pleural mesothelioma (MPM): results in 94 consecutive patients. [Abstract] Proceedings of the American Society of Clinical Oncology 14: A-1083, 356, 1995.  

  13. Sugarbaker DJ, Mentzer SJ, DeCamp M, et al.: Extrapleural pneumonectomy in the setting of a multimodality approach to malignant mesothelioma. Chest 103 (4 Suppl): 377S-381S, 1993.  [PUBMED Abstract]

  14. Markman M, Kelsen D: Efficacy of cisplatin-based intraperitoneal chemotherapy as treatment of malignant peritoneal mesothelioma. J Cancer Res Clin Oncol 118 (7): 547-50, 1992.  [PUBMED Abstract]

  15. Markman M, Cleary S, Pfeifle C, et al.: Cisplatin administered by the intracavitary route as treatment for malignant mesothelioma. Cancer 58 (1): 18-21, 1986.  [PUBMED Abstract]

  16. Rusch VW, Figlin R, Godwin D, et al.: Intrapleural cisplatin and cytarabine in the management of malignant pleural effusions: a Lung Cancer Study Group trial. J Clin Oncol 9 (2): 313-9, 1991.  [PUBMED Abstract]

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Sources of National Cancer Institute Information

Malignant Mesothelioma for Health Professionals


Important
:

This information is intended mainly for use by doctors and other health care professionals. If you have questions about this topic, you can ask your doctor, or call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).

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Mesothelioma Updates

Researchers with the largest Phase III trial to date for mesothelioma, an aggressive cancer affecting the lining of the lung, reported results showing that patients on a new chemotherapy drug regimen live longer and have less pain than those on an older drug. The findings were announced at the annual meeting of the American Society of Clinical Oncology meeting in Orlando, Fla., on May 20, 2002.

Pemetrexed (brand name Alimta™) is a novel antifolate, a class of drugs that targets the folic acid metabolic pathway, which effects availability of certain B complex vitamins. The results of the trial show that tumors shrank in 41 percent of patients on pemetrexed in combination with a more commonly used chemotherapy agent called cisplatin. Only 17 percent of patients receiving cisplatin alone experienced tumor shrinkage. Additionally, those on the pemetrexed combination lived nearly three months longer than those on cisplatin alone.

According to lead author, Nicholas J. Vogelzang, M.D., University of Chicago Cancer Research Center, «This is the largest clinical trial ever conducted in this disease and the 25 to 30 percent improvement in survival for patients on the combination therapy is the first time anyone has documented a significant improvement in patients treated for mesothelioma.»

Malignant pleural mesothelioma is associated with a history of asbestos exposure in about 70 to 80 percent of all cases and there is no approved or very effective chemotherapy for the disease. Researchers hypothesized that pemetrexed might prove effective in treating this disease because it targets key enzymes thought to play a role in allowing the rapid growth of this tumor. 

Early Phase I trial results in 11 patients tested with pemetrexed and cisplatin were promising and a definitive randomized Phase III trial was developed. Since there are no established therapies for this condition, a standard chemotherapy agent called cisplatin that has shown efficacy in treating other diseases, was used as the control arm. The Phase III study initially planned to enroll 456 patients from April 1999 to March 2001. However, after enrolling 150 patients, a high rate of severe toxicity and death was associated with the pemetrexed and cisplatin arm of the trial. Elevated levels of homocysteine, a chemical byproduct that results when proteins are broken down in the blood, were found, which provided a basis for redesign of the trial to reduce the dangerous drug side effects. 

Two hundred and eighty patients were enrolled to the revised protocol. Using a strategy to reduce drug side effects that has been successful in the past, this new protocol added folic acid to the regimen because pemetrexed as an antifolate agent reduces levels of this important vitamin. Folic acid was given prior to and during the trial, and vitamin B12 was given only during the trial. Both vitamins should boost folic acid levels, reduce homocysteine formation, and hence reduce toxicity to pemetrexed. «We now have a significantly less toxic regimen than the one we started with,» said Vogelzang.

Because of the presumed importance of the vitamins to the study, the researchers examined not only the combination therapy versus the single drug therapy, but also looked at the results of patients on the vitamin supplements versus those early enrollees who had not initially received vitamins.

Standard treatment for malignant mesothelioma has been surgery. Surgical treatment rarely results in cure and long-term survival is unusual. Use of radiation therapy and/or chemotherapy following surgery has not improved survival for patients but radiation treatments may alleviate some pain associated with the disease.



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Sources of National Cancer Institute Information

Questions and Answers About Metastatic Cancer

What is cancer?

Cancer is a group of many related diseases that begin in cells, the body’s basic unit of life. The body is made up of many types of cells. Normally, cells grow and divide to produce more cells only when the body needs them. This orderly process helps keep the body healthy. Sometimes cells keep dividing when new cells are not needed. These extra cells may form a mass of tissue, called a growth or tumor. Tumors can be either benign (not cancerous) or malignant (cancerous).

Cancer can begin in any organ or tissue of the body. The original tumor is called the primary cancer or primary tumor and is usually named for the part of the body in which it begins.


What is metastasis?

Metastasis means the spread of cancer. Cancer cells can break away from a primary tumor and travel through the bloodstream or lymphatic system to other parts of the body.

Cancer cells may spread to lymph nodes near the primary tumor (regional lymph nodes). This is called nodal involvement, positive nodes, or regional disease. Cancer cells can also spread to other parts of the body, distant from the primary tumor. Doctors use the term metastatic disease or distant disease to describe cancer that spreads to other organs or to lymph nodes other than those near the primary tumor.

When cancer cells spread and form a new tumor, the new tumor is called a secondary, or metastatic, tumor. The cancer cells that form the secondary tumor are like those in the original tumor. That means, for example, that if breast cancer spreads (metastasizes) to the lung, the secondary tumor is made up of abnormal breast cells (not abnormal lung cells). The disease in the lung is metastatic breast cancer (not lung cancer).


Is it possible to have a metastasis without having a primary cancer?

No. A metastasis is a tumor that started from a cancer cell or cells in another part of the body. Sometimes, however, a primary cancer is discovered only after a metastasis causes symptoms. For example, a man whose prostate cancer has spread to the bones in the pelvis may have lower back pain (caused by the cancer in his bones) before experiencing any symptoms from the prostate tumor itself.


How does a doctor know whether a cancer is a primary or a secondary tumor?

The cells in a metastatic tumor resemble those in the primary tumor. Once the cancerous tissue is examined under a microscope to determine the cell type, a doctor can usually tell whether that type of cell is normally found in the part of the body from which the tissue sample was taken.

For instance, breast cancer cells look the same whether they are found in the breast or have spread to another part of the body. So, if a tissue sample taken from a tumor in the lung contains cells that look like breast cells, the doctor determines that the lung tumor is a secondary tumor.

Metastatic cancers may be found at the same time as the primary tumor, or months or years later. When a second tumor is found in a patient who has been treated for cancer in the past, it is more often a metastasis than another primary tumor.

In a small number of cancer patients, a secondary tumor is diagnosed, but no primary cancer can be found, in spite of extensive tests. Doctors refer to the primary tumor as unknown or occult, and the patient is said to have cancer of unknown primary origin (CUP).


What treatments are used for metastatic cancer?

When cancer has metastasized, it may be treated with chemotherapy, radiation therapy, biological therapy, hormone therapy, surgery, or a combination of these. The choice of treatment generally depends on the type of primary cancer, the size and location of the metastasis, the patient’s age and general health, and the types of treatments used previously. In patients diagnosed with CUP, it is still possible to treat the disease even when the primary tumor cannot be located.

New cancer treatments are currently under study. To develop new treatments, the National Cancer Institute (NCI) sponsors clinical trials (research studies) with cancer patients in many hospitals, universities, medical schools, and cancer centers around the country. Clinical trials are a critical step in the improvement of treatment. Before any new treatment can be recommended for general use, doctors conduct studies to find out whether the treatment is both safe for patients and effective against the disease. The results of such studies have led to progress not only in the treatment of cancer, but in the detection, diagnosis, and prevention of the disease as well. Patients interested in participating in research should ask their doctor to find out whether they are eligible for a clinical trial.





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Sources of National Cancer Institute Information

What is asbestos?

Asbestos is the name for a group of naturally occurring silicate minerals that can be separated into fibers. The fibers are strong, durable, and resistant to heat and fire. Asbestos materials are also long, thin and flexible, so that they can even be woven into cloth. 
Because of these qualities, asbestos has been used in thousands of consumer, industrial, maritime, automotive, scientific and building products. During the twentieth century, some 30 million tons of asbestos were used in industrial sites, homes, schools, shipyards and commercial buildings in the United States. 

There are several types of asbestos fibers, of which three have been used for commercial applications: (1) Chrysotile, or white asbestos, comes mainly from Canada, and has been very widely used in the US. It is white-gray in color and found in serpentine rock. (2) Amosite, or brown asbestos, comes from southern Africa. (3) Crocidolite, or blue asbestos, comes from southern Africa and Australia. 

Amosite asbestos and crocidolite asbestos materials are called amphiboles. This term refers to the nature of their geologic formation. 

Other asbestos fibers that have not been used commercially are tremolite asbestos, actinolite asbestos and anthophyllite asbestos, although these materials are sometimes contaminants in asbestos-containing products. It should be noted that there are non-fibrous, or non-asbestiform, variants of tremolite, anthophylite and actinolite, which do not have the adverse health consequences that result from exposure to commercial forms of asbestos. 


What are asbestos-containing products?

What is common to many asbestos-containing products is that they were (are) used to contain heat (i.e. thermal insulation.) It is impossible to list all of the products that have, at one time or another, contained asbestos. Some of the more common asbestos-containing products are pipe-covering, insulating cement, insulating block, asbestos cloth, gaskets, packing materials, thermal seals, refractory and boiler insulation materials, transite board, asbestos cement pipe, fireproofing spray, joint compound, vinyl floor tile, ceiling tile, mastics, adhesives, coatings, acoustical textures, duct insulation for heating, ventilation and air conditioning (HVAC) systems, roofing products, insulated electrical wire and panels, and brake and clutch assemblies. 
Some of these products contained a very high proportion of asbestos, while others contained small amounts.

Since asbestos causes many diseases like malignant mesothelioma, pleural mesothelioma, peritonial mesothelioma. People are suggested to be aware of this asbestos and its usage. Of these mesothelioma asbestos diseases is effecting when a person is highly exposed to asbestos. 

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Sources of National Cancer Institute Information

Who is at increased risk for developing mesothelioma?

Asbestos has been mined and used commercially since the late 1800s. Its use greatly increased during World War II. Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with asbestos exposure were not known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos mines and mills, producers of asbestos products, workers in the heating and construction industries, and other tradespeople. Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of asbestos exposure in the workplace. People who work with asbestos wear personal protective equipment to lower their risk of exposure. 

The risk of asbestos-related disease increases with heavier exposure to asbestos and longer exposure time. However, some individuals with only brief exposures have developed mesothelioma. On the other hand, not all workers who are heavily exposed develop asbestos-related diseases. 

There is some evidence that family members and others living with asbestos workers have an increased risk of developing mesothelioma, and possibly other asbestos-related diseases. This risk may be the result of exposure to asbestos dust brought home on the clothing and hair of asbestos workers. To reduce the chance of exposing family members to asbestos fibers, asbestos workers are usually required to shower and change their clothing before leaving the workplace.

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What are the risk factors for mesothelioma?

Working with asbestos is the major risk factor for mesothelioma. A history of asbestos exposure at work is reported in about 70 percent to 80 percent of all cases. However, mesothelioma has been reported in some individuals without any known exposure to asbestos. 

Asbestos is the name of a group of minerals that occur naturally as masses of strong, flexible fibers that can be separated into thin threads and woven. Asbestos has been widely used in many industrial products, including cement, brake linings, roof shingles, flooring products, textiles, and insulation. If tiny asbestos particles float in the air, especially during the manufacturing process, they may be inhaled or swallowed, and can cause serious health problems. In addition to mesothelioma, exposure to asbestos increases the risk of lung cancer, asbestosis (a noncancerous, chronic lung ailment), and other cancers, such as those of the larynx and kidney. 

Smoking does not appear to increase the risk of mesothelioma. However, the combination of smoking and asbestos exposure significantly increases a person’s risk of developing cancer of the air passageways in the lung.

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Sources of National Cancer Institute Information

Are new treatments for mesothelioma being studied?


Yes. Because mesothelioma is very hard to control, the National Cancer Institute (NCI) is sponsoring clinical trials (research studies with people) that are designed to find new treatments and better ways to use current treatments. Before any new treatment can be recommended for general use, doctors conduct clinical trials to find out whether the treatment is safe for patients and effective against the disease. Participation in clinical trials is an important treatment option for many patients with mesothelioma. 

People interested in taking part in a clinical trial should talk with their doctor. Information about clinical trials is available from the Cancer Information Service (CIS) (see below) at 1–800–4–CANCER. Information specialists at the CIS use PDQ®, NCI’s cancer information database, to identify and provide detailed information about specific ongoing clinical trials. Patients also have the option of searching for clinical trials on their own. The clinical trials page on the NCI’s Cancer.gov Web site, located at http://cancer.gov/clinical_trials on the Internet, provides general information about clinical trials and links to PDQ. 

People considering clinical trials may be interested in the NCI booklet Taking Part in Clinical Trials: What Cancer Patients Need To Know. This booklet describes how research studies are carried out and explains their possible benefits and risks. The booklet is available by calling the CIS, or from the NCI Publications Locator Web site at http://cancer.gov/publications on the Internet.

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How is mesothelioma diagnosed?

Diagnosing mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient’s medical history, including any history of asbestos exposure. A complete physical examination may be performed, including x-rays of the chest or abdomen and lung function tests. A CT (or CAT) scan or an MRI may also be useful. A CT scan is a series of detailed pictures of areas inside the body created by a computer linked to an x-ray machine. In an MRI, a powerful magnet linked to a computer is used to make detailed pictures of areas inside the body. These pictures are viewed on a monitor and can also be printed. 

A biopsy is needed to confirm a diagnosis of mesothelioma. In a biopsy, a surgeon or a medical oncologist (a doctor who specializes in diagnosing and treating cancer) removes a sample of tissue for examination under a microscope by a pathologist. A biopsy may be done in different ways, depending on where the abnormal area is located. If the cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples. If the cancer is in the abdomen, the doctor may perform a peritoneoscopy. To obtain tissue for examination, the doctor makes a small opening in the abdomen and inserts a special instrument called a peritoneoscope into the abdominal cavity. If these procedures do not yield enough tissue, more extensive diagnostic surgery may be necessary. 

If the diagnosis is mesothelioma, the doctor will want to learn the stage (or extent) of the disease. Staging involves more tests in a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Knowing the stage of the disease helps the doctor plan treatment. 

Mesothelioma is described as localized if the cancer is found only on the membrane surface where it originated. It is classified as advanced if it has spread beyond the original membrane surface to other parts of the body, such as the lymph nodes, lungs, chest wall, or abdominal organs.

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Sources of National Cancer Institute Information

Mesothilioma, Mesotheliema,Mesothiliema,Mesotheleoma Mesosthelioma, Masesthilioma information:

What are the symptoms of mesothelioma?

Symptoms of mesothelioma may not appear until 30 to 50 years after exposure to asbestos. Shortness of breath and pain in the chest due to an accumulation of fluid in the pleura are often symptoms of pleural mesothelioma. Symptoms of peritoneal mesothelioma include weight loss and abdominal pain and swelling due to a buildup of fluid in the abdomen. Other symptoms of peritoneal mesothelioma may include bowel obstruction, blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face. 

These symptoms may be caused by mesothelioma or by other, less serious conditions. It is important to see a doctor about any of these symptoms. Only a doctor can make a diagnosis.