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Management of Mesothelioma By Neoadjuvant Chemotherapy, Followed by Resection and Radiation - A New Approach
A 38-year-old man presented with progressive shortness of breath and right chest pain. He had been a non-smoker and was generally healthy. His employment history included some work as a roofer in his late teens. As an adult, he is a graphic artist. He has no known asbestos exposure.
Chest X-ray revealed a large right pleural effusion. Thoracentesis revealed mesothelial cells. Diagnostic thoracoscopy demonstrated an epithelial neoplasm consistent with mesothelioma of the epithelial type. The initial CT scan demonstrated a large tumor that involved the entire parietal pleura and appeared to extend across the midline, invading the thymic fat and the peri-esophageal region. Subcarinal lymph nodes were enlarged. We thought this tumor to be unresectable, and recommended pre-surgical treatment of the patient with chemotherapy, rather than to commit him to palliative options only. Although the usual aggressive multi-modality treatment for mesothelioma has involved initial resection followed by radiation and chemotherapy, we had seen neoadjuvant chemotherapy be helpful one other time with substantial success.
The patient underwent nine cycles of Adriamycin and Taxol chemotherapy, which he tolerated well. By that time, his tumor had decreased in size substantially to the point where his mediastinal disease appeared much more approachable. He underwent a standard pleural pneumonectomy, involving removal of the right lung, associated parietal pleura, right aspect of the pericardium and phrenic nerve, and the diaphragm. Reconstruction was carried out with a large Gortex patch tented across the lower chest to reconstruct the right hemidiaphragm. A second patch was placed along the right side of the pericardium. His postoperative course was somewhat stormy, with short-term renal failure requiring dialysis, some initial ventilatory insufficiency, and significant depression. After his discharge from the hospital, he underwent consolidative radiation therapy from which he recovered uneventfully. He has had no evidence of recurrence over one year following resection.
While this is still short-term information, this young man has done extremely well to date. Mesothelioma is a very unusual tumor to begin with, but in young people is even more rare. It usually presents in one of two histologic variants, or some combination- epithelial or mesenchymal. Patients with epithelial variants of these tumors are more likely to respond to treatments with reasonable prognosis. This history of asbestos exposure may be very distant, or even absent. While some of the best results that have been reported are those with radical surgery followed by chemotherapy and radiation therapy, this approach of neoadjuvant chemotherapy appears to have some promise for tumors that initially appear unresectable, especially with newer agents that may have increased activity against these tumors. The options for what to do depend significantly upon a patient's overall clinical state. For those in whom complete resection is not possible, palliative pleurectomy without pneumonectomy may nevertheless allow control of the pleural effusion and a marked reduction of the amount of tumor. In some instances, pleurectomy has been shown to extend survival. While always a challenging tumor, and one which often presents in debilitated patients, it is important to be aware of changes in both the palliative and potentially curative options for this disease.
Source
George Haasler, M.D., Associate Professor, Surgery (Cardiothoracic), Medical College of Wisconsin
Paul Ritch, M.D., Professor of Medicine (Hematology/Oncology)
J. Frank Wilson, M.D., F.A.C.R., Chairman, Radiation Oncology