Mesothelioma Chemotherapy

The treatment of Mesothelioma will depend on a number of things including the type of Mesothelioma, how advanced the disease is, the general health and fitness of the patient and their personal preferences.

There are various treatments that may be recommended for Mesothelioma. These include active symptom control, radiotherapy, chemotherapy and surgery. A patient may have just one of these types of treatments or a combination of them.

Chemotherapy can be used to treat Mesothelioma. Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. They work by disrupting the growth of the cancer cells.

Chemotherapy is used in an attempt to shrink the disease and relieve some of the symptoms it is causing. This may improve your quality of life. Some doctors believe it may also help people with Mesothelioma to live a little longer but this is uncertain. Chemotherapy cannot cure Mesothelioma.

Chemotherapy may also be given before or after major surgery for Mesothelioma to prevent or delay the recurrence of the cancer cells. This is called adjuvant treatment.

The chemotherapy drugs that may be used for the treatment of Mesothelioma include Cisplatinum (Platinol), Carboplatin (Paraplatin), Doxorubicin (Adriamycin), Gemcitabine (Gemzar), Mitomycin, Pemetrexed (Alimta), Raltitrexed (Tomudex) and Vinorelbine (Navelbine).

CancerBackup and Macmillan merged in 2008 - the website contains information about individual chemotherapy drugs including how each drug is given and possible side effects that may be experienced with each drug.

In Mesothelioma there is, as yet, no agreement among experts as to when, if at all, during the course of the illness, to use chemotherapy. It is also unknown which is the best drug or the best combination of drugs to treat this disease.

Chemotherapy - How is it Given?

Chemotherapy drugs are carried in the bloodstream to the cancer cells and it can be given in a number of ways. These include:-

By injection into a vein or through a drip 
A fine needle called a cannula will be inserted into a vein, usually in the back of the hand. This procedure is no more painful than any other injection or blood test.

By infusion pump 
These are used to give a controlled amount of drug/s into the bloodstream over a number of hours or days. The pumps are compact and can be carried in a bag or on a belt.

By mouth 
Some chemotherapy drugs are given as a tablet, capsule or liquid.

Chemotherapy Treatment Sessions

On the day of your chemotherapy session, the nurse will explain what is involved and answer any questions you may have before treatment commences.

• You can eat and drink normally on the day of your treatment. However, it is advisable not to have a heavy meal prior to your chemotherapy session.  
• Small amounts of alcohol are safe but it is advised that alcohol is avoided for 48 hours after treatment.  
• Chemotherapy may be given on a hospital Day Ward (where you visit hospital for a few hours for your treatment) or as an inpatient. Your doctor or nurse will discuss this with you.

Chemotherapy - Picture Source - www.show.scot.nhs.uk

Chemotherapy Side Effects

Chemotherapy drugs act on the cancer cells in your body but they also temporarily reduce the number of some of the normal cells in your blood. When the numbers of normal blood cells are lowered you are more at risk of developing infections and you may tire easily.

The side effects of chemotherapy drugs differ from drug to drug. Possible side effects include feeling sick, being sick, loss of appetite, loss or thinning of hair, constipation and diarrhoea, sore mouth and fatigue. Before you start treatment, your doctor or nurse will explain the side effects you may have and offer advice.

As the side effects of chemotherapy can be significant, the benefits of having chemotherapy need to be carefully weighed up against the side effects that may be experienced. Patients are advised to discuss with their oncologist (cancer doctor) about chemotherapy in their individual situation.

Mesothelioma Surgery

Surgery can have an important role within the treatment of malignant Mesothelioma in confirming the diagnosis, assessing the spread of the tumour (stage) and in the control of symptoms.

Surgery and Diagnosis

The diagnosis of malignant pleural Mesothelioma is made most firmly by the inspection of a biopsy of the pleura under the microscope. A diagnosis confirmed by biopsy helps when planning further treatment, for some treatments it is essential and it also verifies claims for compensation.

It may be possible to obtain a reliable biopsy either by the removal of fluid from the chest (pleural fluid cytology) or a needle biopsy whereby a biopsy is obtained under local anaesthetic sometimes guided by a CT or ultra sound scanner. However, particularly in the early stages, negative results by these tests do not rule out the possibility of Mesothelioma. It may be felt that a surgical biopsy is warranted.

Picture Source - www.mayoclinic.org

There are two “keyhole” procedures that can be used. Under a local anaesthetic it is possible to have a medical thoracoscopy. This involves a small camera telescope being introduced through a single 1-2 cm cut from which a biopsy can be taken. If a general anaesthetic is performed, a thoracic surgeon may perform Video Assisted Thoracoscopic Surgery (VATS), through between 1 and 3 such cuts. This allows a larger biopsy to be performed and a full assessment of the pleura to be made.

Video Assisted Thoracoscopic Surgery (VATS) - Picture Source - www.thoracicgroup.com

Staging

If the Mesothelioma is felt to be in an early stage and a surgical resection is being considered, it is essential to fully assess the tumour stage. This may require surgical biopsy of some of the lymph nodes in the centre of the chest (mediastinum). This may be achieved by a biopsy procedure called a mediastinoscopy. This involves a 4cm cut at the base of the neck, above the breast bone (sternum), and the introduction of a telescope (the mediastinoscope) down in front of the windpipe (trachea) into the chest.

Lung Diagram Picture Source - www.usctransplant.org

Radical Surgery

There are two approaches to surgical resection of malignant pleural Mesothelioma; radical and palliative.  

The intention of radical surgery is to remove all or the majority of the visible tumour, dependent on which surgical procedure is carried out. With any cancer type radical surgery is performed with the aim of gaining local control in the area of the tumour, in patients in whom tests have not been able to demonstrate the spread of cancer cells elsewhere in the body. This, of course, cannot be guaranteed, as small deposits of cancer cells may be undetectable. With Mesothelioma, although wide margins of normal tissue around the removed cancer are difficult to achieve, the goal of local control can be obtained. It is important to remember that, unlike radical surgery in breast, bowel and lung cancers, where it is possible to offer the chance of a cure, this is not the case in Mesothelioma. No patient has yet been cured of the disease, even after radical surgery combined with chemotherapy and radiotherapy. Radical surgery is appropriate for only a small number of patients since the majority have disease that has already spread. However, palliative surgery may have an important role in improving and controlling symptoms and maintaining the quality of life. There are two radical surgical options - extrapleural pneumonectomy (EPP) and radical pleurectomy and decortication (P/D).

Radical Surgical Options

Extrapleural Pneumonectomy (EPP)
EPP was a procedure which gained initial favour amongst some surgeons in the UK and overseas, but it is now less commonly performed. It is the most aggressive surgical option but it is only appropriate for a very small number of patients.  Pre-operative tests must demonstrate that patients have good, adequate lung and heart function before acceptance for surgery. EPP involves removing the entire lung and pleura together with the diaphragm and the side of the pericardium (the sac around the heart) in one piece. After removal of the tumour, the diaphragm and pericardium are reconstructed with artificial patches. 

Lung-Sparing Total Pleurectomy (LS-TP)This procedure is also known as Radical Pleurectomy and Decortication (P/D).  With LS-TP, the lung is left in place but the thickened pleural membrane covering it is peeled off and the pleura stripped off the chest wall. The pericardium and diaphragm are often removed, depending on the extent of the tumour.  LS-TP is still, however, a very big operation that is only suitable for patients with sufficient reserves.  As the lung remains in place, and it may even function better after surgery as it can often now expand more easily, recovery from surgery may be quicker and in the longer term quality of life may be preserved or even improved.   However, compared to EPP, it slightly less likely to remove all the tissue that may contain tumour cells and therefore there is a greater chance of recurrence around the operated lung. In addition, it may not be possible to administer as high a dose of radiotherapy to the chest after the operation, as it may damage the underlying lung. LS-TP may be useful  for  patients in whom there is  possible spread  of the mesothelioma to the lymph glands in the centre of the chest (mediastinum).   Not all thoracic surgeons in the UK have experience of this technique  and some will  prefer to operate after a few cycles of chemotherapy have been given. 

Radical Pleurectomy and Decortication (P/D)
P/D is a less radical procedure than EPP and is generally better tolerated by patients. With radical P/D, the lung is left in place but the thickened pleural membrane covering it is skimmed off and the pleura stripped off the chest wall. The pericardium and diaphragm may be removed, depending on the extent of the tumour. As the lung remains in place, and it may even function better after surgery as it can often now expand more easily, recovery from surgery may be quicker. However, compared to EPP, it is not possible to remove all the tissue that may contain tumour cells and therefore there is a greater chance of recurrence around the operated lung. In addition, it may not be possible to administer as high a dose of radiotherapy to the chest after the operation, as it may damage the underlying lung. P/D may be useful in patients who are not fit enough to tolerate the loss of a lung, or those in whom there is spread to the lymph glands in the centre of the chest (mediastinum).

The Mesothelioma and Radical Surgery Trial (MARS)
Radical surgery will not result in a cure and it will reduce the immediate quality of life. One theory is that, following radical surgery, the progression of the disease would be slower, meaning patients would be better off in the medium and long term. By investigating in clinical trials the effects on the quality and length of life after radical surgery, compared to non-surgical treatment, it is hoped that evidence can be gathered to determine the value of surgery. The MARS trial was a study designed to examine the role of EPP in Mesothelioma.  MARS has now closed to recruitment and its final results are awaited.  The next part of the MARS trial will investigate LS-TP in a bigger study: funding for "MARS-2" is being sought.  

Palliative Surgery

The type of operation depends on whether the lung on the affected side will expand or not. If after drainage of the fluid around the lung (pleural effusion) the lung will expand, then the options are either the insertion of sterile talc around the lung to seal the space between the pleural linings (pleurodesis) or the removal of the bulk of the tumour (pleurectomy). Both these procedures can be performed reliably by keyhole surgery Video Assisted Thoracoscopic Surgery (VATS). The MesoVATS trial is comparing outcomes of talc pleurodesis with VATS pleurectomy. Please refer to the Clinical Trials section of this website.

If, however, the lung is encased by tumour and cannot expand after fluid has been drained, then skimming the surface of the lung (decortication) will be required to make it possible for the lung to expand and thereby improve the function of the lung and improve shortness of breath. It is sometimes possible to decorticate the lung by VATS, but the majority of surgeons would perform decortication by opening the chest with a large cut made around the back below the shoulder blades, between the ribs this is called a thoracotomy. A trial to examine whether VATS decortication is worthwhile is being planned. Thoracotomy and decortication is a larger procedure reserved for the younger, fitter patients. In the elderly, more infirm patient, a  tunnelled  indwelling pleural catheter  (TIPC) can be inserted. This is a  permanent drain with a valve which empties the pleural fluid into a vacuum bottle, every few days as required.

Referral for Surgery

Patients can discuss the appropriateness of surgical treatment with the doctor who is currently caring for them. Not all hospitals are able to offer surgical treatment for Mesothelioma. Referral to other hospitals for treatment can be done by the hospital team currently caring for the patient or the GP where this is not feasible.  Mesothelioma UK may be able to help identify the nearest surgical unit, where this is requested.

Conclusion

Surgery is frequently used across the UK to gain a diagnosis and treat pleural effusion. The provision of radical and palliative surgery may vary between parts of the UK and different hospitals. However, not all thoracic surgeons in the UK have experience of radical surgery for malignant pleural Mesothelioma and opinions can differ as to the benefits. It may be necessary for patients to be referred to a specialist centre.

Mesothelioma Radiotherapy

The treatment of Mesothelioma will depend on a number of things including the type of Mesothelioma, how advanced the disease is, the general health and fitness of the patient and their personal preferences.

There are various treatments that may be recommended for Mesothelioma. These include active symptom control, radiotherapy, chemotherapy and surgery. A patient may have just one of these types of treatments or a combination of them.

Radiotherapy is the use of high-energy radiation to kill cancer cells in the body. All the cells in the part of the body being treated have the potential to be affected by the radiotherapy. Normal, healthy cells will to some extent recover. Radiotherapy is used to treat a particular localised area of the body (for example, an area of the chest where pain is felt). The area being treated is often referred to as the radiotherapy field.

A course of radiotherapy is individually prescribed. The course may involve several doses, usually referred to as fractions, or just a few. The number of fractions required would depend on the amount of tissue that is to be treated. Radiotherapy treatment is not routinely given over the weekend.

Radiotherapy can be used in Mesothelioma to reduce the size of the tumour to help to relieve symptoms, such as pain or discomfort.

Radiotherapy can also be given to the scar left by a biopsy, drainage tube or operation. This is to prevent the Mesothelioma from spreading into the site as small microscopic deposits may have occurred during the insertion and removal of drains, biopsy needles or surgical instruments.

In Mesothelioma radiotherapy may also be given to much larger areas. The whole chest area on the affected side of a patient can be treated following surgery, to kill diseased cells that it was not possible to remove during surgery. (Please see the Surgery section for further details about Surgery and Mesothelioma).

In Mesothelioma small scars are often treated with 3 doses (fractions) of radiotherapy. When treating to relieve symptoms such as pain up to 10 doses (fractions) may be necessary. When given after surgery to a large area up to 30 treatments may be required.

Before Radiotherapy Begins

Before your treatment begins you will be asked to attend the Radiotherapy Department in order to plan your radiotherapy. Depending on the course of treatment you have been prescribed it may be necessary for X-rays of the area to be treated to be taken by a special machine called a simulator. There may be an interval between this visit to the Radiotherapy Department and the start of the radiotherapy.

Radiotherapy Sessions

The radiographer will ensure that you are comfortable on the couch in the treatment room before starting the session. During your treatment you will be left alone in the room. You will be able to talk to the radiographer through an intercom and the radiographer will be watching you from the next room.

• Radiotherapy does not make you radioactive – it is safe for you to be with other people (including children) throughout your treatment. 
• You can eat and drink normally before and after each radiotherapy session. 
• Radiotherapy treatments are totally painless (like having an ordinary x-ray). 
• You will be asked to remain still during treatment but you can breathe normally. 
• Each radiotherapy session lasts from a few seconds to several minutes.

Radiotherapy - Picture Source - www.cancerbacup.org.uk

Radiotherapy Side Effects

Radiotherapy can cause side effects such as poor appetite, feeling sick, being sick and tiredness. Some patients also experience soreness and itchiness of the skin and difficulty in swallowing. The extent of the side effects does depend on the dose of the radiotherapy, length of treatment and the size of the area being treated. If you are receiving radiotherapy to a scar or drain site usually side effects are limited to soreness and itchiness of the skin. However, if a larger area is being treated, as well as skin problems, tiredness, difficulty in swallowing and poor appetite can be experienced. If you are undergoing an extensive course of radiotherapy it is possible that other organs within the treatment field, such as the heart, liver, spleen and kidneys, will suffer long-term damage, however this is rare.

If you are having radiotherapy you should discuss the side effects with your radiographer, doctor or nurse. They will advise you who to contact should you experience side effects in between your hospital visits.

Once your course of treatment is finished the side effects should gradually disappear. 

What are causes Mesothelioma?

Exposure to asbestos is responsible for up to 9 out of 10 mesothelioma cases. There are thought to be other rare causes of the disease but none are fully understood at this time. The disease has been described in medical literature since 1870 although the first suspicion linking asbestos and mesothelioma did not appear in the U.K. until 1935 and a definite link was not reported until 1960.

What is Asbestos?

Asbestos is a natural fibrous mineral that is widely distributed in nature. Its name derives from the Greek meaning ‘inextinguishable’, which suggests its ability to resist heat and fire have always been understood. It is the ability to resist heat and fire that resulted in asbestos being used widely in industry, shipbuilding and construction particularly during and after World War II. Currently the largest producers of asbestos are Russia, China and Canada. Russia and China use a majority within their own country however Canada dominates the export market. There are still over 100 countries producing asbestos containing pipes and sheets to be used as low cost building material.

Raw Blue Asbestos Picture Source -www.safetyline.wa.gov.au       

There are three main types of asbestos, blue (crocidolite), brown (amosite) and white (Chrysotile). They are all harmful but blue and brown asbestos are recognised as the most hazardous and have not been imported into the UK since 1985. However, they are still present in buildings and equipment produced before the ban. White asbestos was only banned in the U.K. in 1999.

Processed Blue Asbestos Picture Source - www.asbestos-mesothelioma.com

It is asbestos dust or airborne fibres, which cause harm when inhaled or ingested. Asbestos materials left undisturbed probably poses no significant threat. Asbestos fibres are very fine and if they are breathed in they can reach the smallest areas of the lung where they cannot be breathed or coughed out. Once they have lodged in the lung the body’s defence mechanism tries to break them down and remove them which leads to swelling and inflammation in the surrounding area. The fibres can also penetrate the edge of the lung and settle in the pleural lining. The fibres can also be swallowed and in a similar way can lodge in the abdomen and work their way to the peritoneum that lines the abdomen where the same swelling and inflammation can occur.

If you have been exposed to asbestos at any time you are potentially at risk although it should be made clear that the majority of people who have been exposed to asbestos dust do not suffer ill health as a result. There is no way of identifying who or why some people go on to suffer and others remain unaffected.

Asbestos Removal

Generally, asbestos is only a risk if you disturb or damage it and cause fibres to be released into the air. If asbestos containing materials are in good condition and in a position where they are not going to be disturbed or damaged then it may be safer to leave them where they are and ensure that any risks are properly managed. Professional advice should be sought.

Asbestos was used in many different products and buildings from the 1950s to the mid 1980s. Many homes may, therefore, contain asbestos containing material.

If you are concerned about asbestos in the home, and the potential removal of it, you should contact the Local Council in your area. They will be able to provide professional advice.

What are the symptoms of Mesothelioma?

It can take many years after being exposed to asbestos for mesothelioma to occur. The length of time taken is referred to as the latency period and is usually between 15-45 years.

In the early stages when the mesothelioma is present as small lumps it will not show up on any scans or x-rays and is unlikely to cause any symptoms. As it progresses pleural and peritoneal mesothelioma can both cause general symptoms such as sweating, tiredness, loss of appetite and weight loss. As the disease advances pleural mesothelioma typically causes patients to feel breathless and/or experience chest pain.

Breathlessness may be due to a combination of factors. The pleura being thickened can act like a rind around the lung restricting its movement and preventing the lung from expanding.

Pain can be quite severe as the mesothelioma can extend into the tissues surrounding the pleura including nerves and bone. A variety of medication is available to combat any pain experienced. Fluid may also accumulate in the space between the two layers of the pleura occupying space and again this restricts lung expansion. A cough or altered voice is also sometimes experienced. Peritoneal mesothelioma often causes swelling and pain in the abdomen.

About Mesothelioma

What is Cancer?

Firstly it is important to understand that cancer is not a single illness, there are very many different types and mesothelioma is just one type. Our bodies are made of tiny building blocks called cells, cancer is a disease of these cells. Cells from different parts of the body look and work differently and millions of new cells are made everyday to replace those lost through old age or wear and tear. Throughout the body new cells are produced when existing cells divide into two and there is normally a perfect bal`nce between those that are dying and those that are dividing. This vital balance is controlled by a very complicated process, if control of this process is lost it can lead to too many cells being produced which results in a tumour. Most tumours are not cancerous (sometimes described as benign) and they remain in the area where they first developed. A wart is a common example. The development of cancer involves a change in the quality of the cells as well an increase in the quantity. They become more aggressive, destructive and independent of normal cells. They are able to invade surrounding tissues, glands and blood vessels and thus spread away from where they started to divide and grow. When the cancer cells reach a new site they may go on dividing and form a new tumour, this is often referred to as a secondary or metastasis (secondary).

What is Mesothelioma?

In the United Kingdom almost 2000 people a year are diagnosed with mesothelioma. It is also known as ‘diffuse’ or ‘malignant’ mesothelioma. Mesothelioma is a form of cancer that affects the Mesothelium, which is a thin membrane that lines the inner surface of the chest wall where it is known as the pleura, and abdomen, where it is known as the peritoneum. It also surrounds the organs found within these cavities for example the heart, lung and intestines. It is far more common to have mesothelioma in the chest than in the abdomen, there is approximately 1 case of peritoneal mesothelioma to every 12 cases of pleural mesothelioma.

Pleural Mesothelioma

The pleural lining has two layers: the visceral (inner) layer is next to the lung and the parietal (outer) layer lines the chest wall. The pleura produces fluid that lubricates the space between the two layers, this allows the two layers to slide comfortably over each other as we breathe in and out.

Pleural mesothelioma causes the pleura to thicken. This thickening of the pleura might begin to press onto the lungs or attach itself to the inside of the chest wall. In either case the expansion of the lung becomes progressively restricted by the tumour. Fluid, sometimes several litres, can collect between the two layers of the pleura; this affects the lungs ability to expand and causes the person to feel breathless. This is known as a pleural effusion.

Picture Source - www.mesotheliomacenter.org

Peritoneal Mesothelioma

The peritoneum also has two layers the inner (visceral) layer which is next to the abdominal organs and the outer (parietal) layer which lines the abdominal wall. Peritoneal mesothelioma causes the peritoneum to thicken and fluid to collect in the abdomen. This collection of fluid is called ascites and causes the abdomen to swell. Because pleural mesothelioma is more common and often spreads to the peritoneal cavity, it is sometimes necessary to determine if pleural mesothelioma is the primary cancer.

Asbestos Disease - Mesothelioma

It is medically accepted that asbestos causes various types of serious disease, including a very rare cancer of the lining of the lung or abdomen, called mesothelioma; cancer of the lung andasbestosis, which is a fibrosis or scarring of the lining of the lungs. Also associated with asbestos exposure are pleural changes, which may or may not cause impairment, depending upon the severity.

There is also a distinct connection between asbestos exposure and cancers of the digestive tract such as esophageal, laryngeal, stomach, and colon-rectal cancers.

The  latency period for asbestos related disease is approximately fifteen to fifty years, from the first exposure. Often a person may contract more than one form of disease. Proving that you suffer from an asbestos related disease is one component of your asbestos case.

Frequently Asked Questions about Mesothelioma

Q: What is Mesothelioma?

A: Mesothelioma is a type of cancer. The National Cancer Institute describes Mesothelioma as a rare form of cancer in which malignant cells are found in the sac lining the chest (the pleura), the lining of the abdominal cavity (the peritoneum), or the lining around the heart (the pericardium).

Q: How do you get Mesothelioma?

A: Mesothelioma usually results from asbestos exposure at work. Employees with prolonged exposure over an extended period of time face the highest risk, but cases of mesothelioma have been documented after minimal exposure as well. Workplaces with shingles, flooring materials, cement, brake linings, textiles, insulation containing asbestos and insulated machinery pose the greatest risk. Asbestos particles that are friable may be inhaled or swallowed, causing serious health problems.

Q: How will I know if I have Mesothelioma?

A: Symptoms of mesothelioma include pain and swelling, shortness of breath, coughing, weight loss, anemia, and fever. While doctors may suspect mesothelioma in a particular case, they need a tissue sample to give a final diagnosis. If you think you may have mesothelioma, you should see a doctor as soon as possible.

Q: How long after exposure does Mesothelioma occur?

A: Mesothelioma can develop decades after exposure. Some workers exposed in the mid-20^th century are just now being diagnosed with mesothelioma. The disease takes a long time to develop, which can make it difficult to identify the source of the exposure. Cooney & Conway attorneys and investigators have discovered asbestos in products that consumers and employers thought to be harmless including: insulation, gaskets, clothing,  joint compound, construction materials, machinery and consumer products. Cooney and Conway extensively interviews witnesses and searches documents to determine sources of exposure.

Q: Does smoking increase my risk of developing Mesothelioma?

A: No.

Q: Is my family at risk?

A: There is strong evidence that family members of asbestos workers have an increased risk of developing mesothelioma as a result of exposure to asbestos dust carried home on the clothes of the worker.

Q: How is Mesothelioma treated?

A: Treatment options depend on the location of the cancer, the stage of the disease, and the patient's age and general health. Standard treatment options include surgery, radiation therapy, and chemotherapy, either alone or in combination. Clinical trials are underway to develop new and better methods of treatment.

Q: What are my legal rights if I have developed Mesothelioma?

A: If you believe you have been diagnosed with mesothelioma you may have a legal action. An experienced attorney at Cooney & Conway can advise you on whether you may be able to bring a lawsuit to recover damages for medical expenses, pain and suffering, lost income, loss of society, and other losses.

Q: I've read in the paper that many others are suffering from mesothelioma as a result of asbestos exposure. Can we pursue our claims together, as a group?

A: Although mesothelioma cases are filed individuallyl, there are advantages in hiring a firm with many mesothelioma cases. Extensive research regarding product identification, location of documents and legal research in past cases can be used in your case at little or no cost. In addition, past depositions and trial testimony in previous cases may be used to prove your case. The extensive experience and past successes of Cooney & Conway is one of the reasons why attorneys across the United States ask Cooney & Conway to assist their clients.