Treatment options are often determined by the stage of mesothelioma a patient is in. There are three staging systems currently in use for pleural mesothelioma and each one measures somewhat different variables; peritoneal mesothelioma is not staged.

Staging is the term used to describe the extent of a patient's cancer, based on the primary tumor and its spread in the body. It can help the medical team plan treatment, estimate prognosis and identify clinical trials for which the patient may be eligible.

Staging is based on a knowledge of how the cancer develops, from the primary tumor, to the invasion of nearby organs and tissues, to distant spread or metastasis. Staging systems have evolved over time, and they continue to change as scientists learn more about cancer. Some staging systems cover many different types of cancer, while others focus on more specific cancers. The TNM (primary tumor, regional lymph nodes, distant metastasis) is the most common staging system for mesothelioma.

Some elements common to most staging systems are:

* Location of the primary tumor.
* Size and number of the tumors.
* Lymph node involvement.
* Cell type and tumor grade.
* Metastasis.

Many cancer registries, such as the National Cancer Institute's Surveillance, Epidemiology, and End Results Program (SEER) use summary staging, a system used for all types of cancer. Summary staging groups cancer into five main categories:

* In situ - cancer that is present only in the layer of cells in which it began.
* Localized - cancer that is limited to the organ in which it began with no evidence of spread.
* Regional - cancer that has spread from the primary site to nearby lymph nodes or organs.
* Distant - cancer that has spread from the primary site to distant lymph nodes or organs.
* Unknown - cases where not enough information exists to indicate stage.

Several types of testing may be used to help doctors determine stage, and to formulate a treatment plan.

* Physical examinations. The doctor examines the body by looking, feeling and listening to anything out of the ordinary.
* Imaging techniques. Procedures such as x-rays, CT scans, MRIs and PET scans may show the location, size of the tumor and whether the cancer has spread.
* Laboratory tests. Studies of blood, urine, fluid and tissue can provide information about the cancer. Tumor markers, sometime elevated when cancer is present, may provide information.
* Pathology reports. Results of the examination of tissue samples can include information about the size of the tumor(s), extension into adjacent structures, type of cells and grade of the tumor. Results of the examination of cells in fluid, such as that from a mesothelioma-related pleural effusion, may also provide information.
* Surgical reports. Observations about the size and appearance of the tumor(s), lymph nodes and nearby organs.

Staging information should be provided to the patient by his doctor so that potential treatment plans can be discussed. Stage of the mesothelioma, as well as consideration of other factors such as age, health status and the patient's wishes may dictate different treatment options.

The oldest staging system and the one most often used is the Butchart System which is based mainly on the extent of primary tumor mass and divides mesotheliomas into four stages. The more recent TNM system considers variables of tumor in mass and spread, lymph node involvement, and metastasis. The Brigham System is the latest system and stages mesothelioma according to resectability (the ability to surgically remove) and lymph node involvement.

Butchart System – extent of primary tumor mass

* Stage I:
Mesothelioma is present in the right or left pleura and may also involve the diaphragm on the same side.
* Stage II:
Mesothelioma invades the chest wall or involves the esophagus, heart, or pleura on both sides. Lymph nodes in the chest may also be involved.
* Stage III:
Mesothelioma has penetrated through the diaphragm into the lining of the abdominal cavity or peritoneum. Lymph nodes beyond those in the chest may also be involved.
* Stage IV:
There is evidence of metastasis or spread through the bloodstream to other organs.

TNM System -- variables of T (tumor), N (lymph nodes), M (metastasis)

* Stage I: Mesothelioma involves right or left pleura and may also have spread to the lung, pericardium, or diaphragm on the same side. Lymph nodes are not involved.
* Stage II: Mesothelioma has spread from the pleura on one side to nearby lymph nodes next to the lung on the same side. It may also have spread into the lung, pericardium, or diaphragm on the same side.
* Stage III: Mesothelioma is now in the chest wall, muscle, ribs, heart, esophagus, or other organs in the chest on the same side with or without spread to lymph nodes on the same side as the primary tumor.
* Stage IV: Mesothelioma has spread into the lymph nodes in the chest on the side opposite the primary tumor, or extends to the pleura or lung on the opposite side, or directly extends into organs in the abdominal cavity or neck. Any distant metastases is included in this stage.

Brigham System: (variables of tumor resectability and nodal status)

* Stage I: Resectable mesothelioma and no lymph node involvement
* Stage II: Resectable mesothelioma but with lymph node involvement
* Stage III: Unresectable mesothelioma extending into chest wall, heart, or through diaphragm, peritoneum; with or without extrathoracic lymph node involvement
* Stage IV: Distant metastatic disease

Symptoms of Mesothelioma



Diagnostic Procedures

As previously mentioned in the "Symptoms of mesothelioma" section of this website, a diagnosis of mesothelioma from fluid is many times inconclusive. Given this fact, diagnostic surgery becomes a necessary next step in confirming and staging mesothelioma.

Thoracoscopy enables a physician to evaluate the pleural cavity and to conduct multiple tissue biopsies under direct vision. In up to 98% of cases, a definitive diagnosis can be obtained. Often, chemical pleurodesis aimed at relieving the accumulation of fluid in the intrapleural space, can be accomplished during the same procedure. It is also possible to gauge the extent of the tumor, and make a determination of surgical resectability. While less invasive than an open biopsy, it can only be performed on patients where tumor has not obliterated the pleural space.

VATS, or video-assisted thoracic surgery is an alternative to thoracoscopy, although because of its more invasive nature, concerns of tumor seeding increase. By utilizing small incisions, the physician can view the pleural space with the assistance of a camera, and obtain sufficient tissue samples for analysis by a pathologist. Extent of the tumor (i.e., pleural involvement, chest wall invasion) may also determined, and recommendation as to the type of debulking procedure necessary can be made at this time.

Mediastinoscopy is sometimes used as an aid in staging extent of disease when enlarged nodes are seen using imaging techniques.

Laproscopy is used in mesothelioma patients in cases where imaging techniques suggest possible invasion of the tumor through the diaphragm. This information can be important in evaluating a patient for potential pleurectomy or extrapleural pneumonectomy.

Symptoms of Mesothelioma

Mesothelioma Palliative Procedures

Mesothelioma Palliative Procedures

Palliative surgical procedures are those which treat a symptom of mesothelioma, without aggressively treating the disease itself.

Chest Tube Drainage and Pleurodesis is considered the most common of palliative treatments. Fluid build-up, or pleural effusion, is most often the first symptoms of mesothelioma which will prompt mesothelioma patients to seek medical attention. Once this effusion has occurred, it is many times persistent, returning rapidly after initial thoracentesis (draining of the fluid). In order to eliminate this problem, the pleural space must be closed. This is accomplished by use of a talc slurry or other sclerosing agent which produces an adhesion.

Thoracoscopy and Pleurodesis is done in conjunction with VATS using a powdered form of talc versus talc slurry. Both this and chest tube drainage and pleurodesis will be only effective if there is no tumor encasing the lung which restricts its expansion.

Pleuroperitoneal Shunt plays a limited role in palliation for several reasons. It involves placement of a catheter run under the skin from the pleural to the peritoneal cavity. Obstruction of the catheter and possible seeding of the tumor into the abdominal cavity may be concerns.

Pleurectomy, used as a palliative procedure, may be performed where more extensive surgery is not an option. In these cases, it is understood that all visible or gross tumor will not be removed. It is considered the most effective means of controlling pleural effusion in cases where the lung's expansion is restricted by disease.
symptom of mesothelioma,

Potentially Curative Procedures for Mesothelioma

Potentially Curative Procedures for Mesothelioma

These procedures are performed with "curative intent". Their goal is removal of all gross disease, with the knowledge that microscopic disease will most likely remain. Adjuvant therapy (another form of treatment in addition to the primary therapy) is typically aimed at eliminating residual disease.

For Pleural Mesothelioma:

* Pleurectomy/Decortication is usually performed on patients with early stage disease (Stage I and selected Stage II), and attempts to remove all gross tumor. If it is found that all tumor can not be removed without removing the lung, this may be done at the same time and is called pneumonectomy.
* Extrapleural Pneumonectomy is considerably more radical than other surgical approaches, and should be carried out by surgeons with great expertise in evaluating patients and performing the procedure itself. (See Finding Specialists.) Because in the past surgery alone has failed to effect a cure, or even to help prolong life for any extended period of time, it is currently being combined with traditional chemotherapy and/or radiation, or other new approaches such as gene therapy, immunotherapy or photodynamic therapy.

General Patient Selection Criteria for Extrapleural Pneumonectomy

Extrapleural pneumonectomy is a serious operation, and doctors experienced in this procedure choose their patients carefully. It is up to each individual surgeon to advise the patient on its feasibility and to conduct whatever tests he/she feel are necessary to optimize the patient's chances for survival and recovery. Following is a general list of patient selection criteria. This list may not be all inclusive, and may vary according to the preference of the surgeon.
o Karnofsky Performance Status score of >70. This score relates to what symptoms of disease the patient may be experiencing and how well they are able to conduct their daily activities. Some surgeons may require a higher performance status than others.

o Adequate renal (kidney) and liver function tests; no significant kidney or liver disease.
o Normal cardiac function per electrocardiogram and echocardiography.
o Adequate pulmonary function to tolerate the surgery.
o Disease limited to the ipsilateral hemithorax (the same side of the chest in which the
mesothelioma is located) with no penetration of the diaphragm, extension to the heart or extensive involvement of the chest wall.
o Age of the patient is taken into consideration, but may not be as important as their overall status.

Surgeries of this nature should always be done with a complete understanding of the possible benefits and risks involved. If you are considering surgery as a treatment option, speak openly with your doctor about your concerns, and be sure all of your questions are answered to your satisfaction.

For Peritoneal Mesothelioma:

* Cytoreductive Surgery is aimed at removing all or nearly all of the gross or visible tumor in the peritoneal cavity. In order to treat any remaining cancer cells, Intra-Peritoneal Hyperthermic (heated) Chemotherapy (IPHC) is then delivered to the abdominal cavity. The type of chemotherapy drug used may vary according to the physician’s preference. Click here for more on treatment of peritoneal mesothelioma.



New approaches to treat malignant mesothelioma are currently being tested. They often combine traditional treatments or include something entirely new. They include:

* Angiogenesis and Anti-angiogenesis Drugs

Although progress has been made in the early detection of cancer, and in improved treatment options once cancer is diagnosed, there are still many cancers, including mesothelioma, which can not be cured and remain difficult to treat effectively. In recent years, researchers have learned a great deal about how cancer cells differ from normal cells and, in an effort to find drugs without the potentially severe side effects of chemotherapy, have now discovered drugs which target the tumor itself while sparing the body’s normal cells. One such group are the anti-angiogenesis drugs.

* Immunotherapy, sometimes called biological therapy, uses the body's own immune system to protect itself against disease. Researchers have found that the immune system may be able to recognize the difference between healthy cells and cancer cells, and eliminate those that become cancerous. Immunotherapy is designed to repair, stimulate, or enhance the immune system's natural anticancer function.

Substances used in immunotherapy, called biological response modifiers (BRMs) alter the interaction between the body's immune defenses and cancer, thereby improving the body's ability to fight disease. Some BRMs, such as cytokines and antibodies, occur naturally in the body, however, it is now possible to make BRMs in the laboratory that can imitate or influence natural immune response agents. These BRMs may:

o Enhance the immune system to fight cancer cell growth.
o Eliminate, regulate, or suppress body responses that permit cancer growth.
o Make cancer cells more susceptible to destruction by the immune system.
o Alter cancer cell's growth patterns to behave like normal cells.
o Block or reverse the process that changes a normal cell into a cancer cell.
o Prevent a cancer cell from spreading to other sites.

Many BRMs are currently being used in cancer treatment, including interferons, interleukins, tumor necrosis factor, colony-stimulating factors, monoclonal antibodies, and cancer vaccines.

* Photodynamic therapy (PDT) is a type of cancer treatment based on the premise that single-celled organisms, if first treated with certain photosensitive drugs, will die when exposed to light at a particular frequency. PDT destroys cancerous cells by using this fixed frequency light to activate photosensitizing drugs which have accumulated in body tissues.

In PDT, a photosensitizing drug is administered intravenously. Within a specific time frame (usually a matter of days), the drug selectively concentrates in diseased cells, while rapidly being eliminated from normal cells. The treated cancer cells are then exposed to a laser light chosen for its ability to activate the photosensitizing agent. This laser light is delivered to the cancer site, (in the case of mesothelioma, the pleura), through a fiberoptic device that allows the laser light to be manipulated by the physician. As the agent in the treated cells absorbs the light, an active form of oxygen destroys the surrounding cancer cells. The light exposure must be carefully timed, so that it occurs when most of the photosensitizing drug has left the healthy cells, but is still present in cancerous ones.

The major side effect of PDT is skin sensitivity. Patients undergoing this type of therapy are usually advised to avoid direct and even indirect sunlight for at least six weeks. Other side effects may include nausea, vomiting, a metallic taste in the mouth, and eye sensitivity to light. These symptoms may sometimes come as a result of the injection of the photosensitizing agent.

* Gene therapy is an approach to treating potentially fatal or disabling diseases by modifying the expression of an individual's genes toward a therapeutic goal. The premise of gene therapy is based on correcting disease at the DNA level and compensating for the abnormal genes.

Replacement gene therapy replaces a mutated or missing gene, most often a tumor suppressor gene, with a normal copy of that gene which serves to keep cell growth and division under control. The p53 gene, the most common gene mutated in cancer has become a prime target for gene replacement, and has met with some success in inhibiting cell growth, inhibiting angiogenesis (the development of a tumor's blood supply), and inducing apoptosis (cell death).

Knockout gene therapy targets the products of oncogenes (a gene that can induce tumor formation) in an effort to render them inactive and reduce cell growth.

With constantly expanding knowledge of the genes associated with cancer, their functions, and the delivery systems used in administering these genes, gene therapy has a promising future.
* Complementary and alternative medicine covers a wide range of healing philosophies that conventional medicine does not commonly accept or make available to its patients. Some of these practices include the use of acupuncture, herbs, homeopathy, therapeutic massage, and Far Eastern medicine to treat health conditions.

These therapies may be used alone as an alternative to conventional medicine, or in addition to conventional medicine, in which case they are referred to as complementary. Many are considered holistic, meaning their focus is to treat the whole patient - physically, mentally, emotionally, and spiritually. These treatments are not widely taught as a part of the medical curriculum, are not generally used in hospitals, and, for the most part, are not covered under insurance policies.

Many cancer patients try various complementary and/or alternative medicine techniques during the course of their treatment, and although they may not work for everyone, some patients benefit by managing their symptoms or side effects. One important caveat, is to discuss any complementary or alternative treatments you may be considering with your doctor to be sure nothing interferes with your conventional care. For instance, dietary supplements such as herbs or vitamins may be "natural", but not necessarily "safe". They may lessen the effectiveness of certain anticancer drugs, or when taken with other drugs or in large doses, may actually cause harm. Since supplements of this nature are not governed by the FDA (Food and Drug Administration), and a prescription is not necessary to purchase, it is up to the consumer to make informed and conscientious decisions regarding their use.

Your personal physician may be able to advise you about the use of complementary and alternative treatments and therapies, and how they relate to mesothelioma.

The combinaton of complementary and conventional therapies is sometimes referred to as integrative medicine.
* Unconventional methods of cancer treatment make claims that can not be scientifically substantiated. They commonly claim to be effective against cancers that are considered incurable, and tout treatments with relatively few, if any, side effects.

The use of these unconventional methods may result in the loss of valuable time and the opportunity to receive potentially effective therapy. It is always important to remain in the care of a qualified physician who uses accepted methods of treatment or who is participating in scientifically designed investigational therapies.

Mesothelioma Symptoms 2

Mesothelioma Symptoms 2

Mesothelioma is a unique disease in that symptoms do not usually manifest themselves until anywhere from 20 to 50 years after exposure to asbestos. For patients and doctors, this is the most frustrating aspect of the disease. The latency period of mesothelioma is lengthy, making the disease undiagnosable until its later stages when symptoms finally begin to appear and little can be done to slow the progress of the disease.
Recognizing Symptoms

Just like any other disease, the symptoms of mesothelioma vary from case to case and with the severity of the illness. The type of mesothelioma - whether pleural, peritoneal, or pericardial - also determines what the symptoms might be. Often times, the general overall health of the individual, as well as his/her age, may also play a role in how the patient is affected by the disease and which symptoms are most bothersome.

One of the most difficult problems with diagnosing mesothelioma and connecting the symptoms with the disease is the fact that so many of the symptoms - both individually and in tandem - can easily be mistaken for other more common diseases like flu, pneumonia, bronchitis, heart disease, and others.

A doctor well versed in symptoms of mesothelioma treatment will take time to investigate a patient's history and hopefully connect past exposure to asbestos with the symptoms. Patients, however, can do their part as well. Anyone that was ever exposed to asbestos, even if it was decades ago, should inform their doctor of the exposure. That information will not only aid the doctor in diagnosis but will also help eliminate the need for many costly and uncomfortable tests that may be ordered while fishing for a diagnosis.

Tests are being developed that will help diagnose mesothelioma at an earlier stage, even before the most common symptoms appear. It is hoped that these tests will aid in treating the disease before it reaches its most advanced stages.

The Symptoms of Mesothelioma

The Symptoms of Mesothelioma

As was stated previously, symptoms of mesothelioma can vary, but the most common general symptoms are:

* Shortness of breath or difficulty breathing
* Coughing
* Pain in chest or abdomen
* Fluid in the chest, lungs, or abdomen
* Weight loss
* Loss of appetite
* Inability to sleep
* Husky voice
* Difficulty swallowing

It is the first two symptoms that generally bring a patient to the doctor's office. Both difficulty breathing and persistent coughing are caused by the lung's inability to expand properly due to tumors in the pleural region. The growing tumors cause the pleura, pericardium, or peritoneum to expand, thus allow fluid to enter. That generally causes pain - acute to severe - in the affected regions, such as the chest or abdomen. Breathing difficulties also make it hard to sleep and often result in loss of appetite and, eventually, weight loss.

Depending on the type of mesothelioma diagnosed - pleural, pericardial, or peritoneal - symptoms might vary from the above, which pertain mostly to pleural mesothelioma, the most common form of the disease.

Common symptoms of peritoneal mesothelioma might include:

* Abdominal pain, acute to severe
* Swelling of the abdominal region due to fluid accumulation
* Breathing difficulties
* Loss of appetite resulting in weight loss
* Bowel obstruction
* Nausea
* Vomiting
* Weakness
* Fever
* Anemia

Common symptoms of pericardial mesothelioma might include:

* Chest pain, ranging from uncomfortable to severe
* Shortness of breath
* Heart palpitations
* Persistent coughing
* Extreme fatigue after minimal activity or exertion

Because the three types of the disease are similar but centered in different parts of the body, the patient is likely to have symptoms that overlap. For example, nearly all meso patients suffer from shortness of breath and fatigue, but the pain may be more apparent in the abdominal/stomach area for peritoneal patients and in the chest for those with pleural or pericardial mesothelioma.