|
|
Mesothelioma
Treatment
Abstracts
& Articles
Management
of Mesothelioma By Neoadjuvant
Chemotherapy, Followed by Resection and
Radiation-A New Approach
- 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.
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.
If
you have any questions regarding treatment
options or your legal rights, please
contact
us.
|
|