Treatment approaches to malignant mesothelioma consist of curative procedures and practices of palliative care.
As their label implies, potentially curative procedures are done with the intent to cure patients of the disease. The main goal of these procedures is the complete removal of gross disease. Residual microscopic disease is typically blasted away with the use of adjuvant therapy, which usually takes the form of a combination of chemo and radiotherapy. Studies have shown that a trimodality approach that combines surgery with radiation and chemotherapy or with other new approaches such as gene therapy, photodynamic therapy or immunotherapy are more effective at arriving a cure.
An example of a potentially curative procedure that is done for pleural mesothelioma is pleurectomy or decortication. This is usually done on patients who are in stages I and II of the malignant mesothelioma. Removal of all gross tumor is attempted with this procedure. If the complete removal of the tumor necessitates the removal of the lung, then a concurrent pneumonectomy is also performed.
A more radical approach that can be used to potentially cure pleural mesothelioma is Extrapleural Pneumonectomy. Since this is a more radical procedure, more expertise is also required of the surgeons. Patients have to meet a certain set of criteria before extrapleural pneumonectomy can be performed on them. The criteria include a Karnofsky Performance Status score of >70, adequate kidney and liver functions, within normal electrocardiogram and echocardiography results, adequate pulmonary function tests, limitation of the disease to just the ipsilateral hemithorax with no involvement of either the diaphragm, heart or chest wall, and age of the patient. The age is not given as much weight as the overall functional status of the patient.
For peritoneal mesothelioma, a cytoreductive surgery is performed to possibly effect a cure. As with the approaches used for pleural mesothelioma, this is done with the aim of removing all gross tumor. Cytoreductive surgery is typically combined with Intraperitoneal Hyperthermic Chemotherapy (IPHC) which is aimed wipe out any remaining microscopic cancer cells.
For patients with the more advanced stages of malignant mesothelioma for which the aforementioned curative approaches are not warranted, treatment should be geared towards the use of palliative procedures.
Palliative procedures are aimed at relieving the symptoms brought about by the disease in the hopes of improving the patient's quality of life. Chest Tube drainage and pleurodesis is a common palliative treatment employed to relieve fluid buildup or effusion in the chest cavity. Since malignant pleural effusions are usually persistent, after the initial drainage, pleurodesis is often performed to permanently close the pleural space and prevent the fluid from re-accumulating. Talc powder or other sclerosing agents are used as adhesives. Thoracoscopy with pleurodesis is another palliative procedure with a similar strategy. Both these procedures can only be done if the tumor has not yet encased the lungs. The unrestricted expansive capacity of the lungs has to be still intact for these two procedures to work. In cases where in the disease is effecting a restriction on the lung's expansion, a pleurectomy is the most effective treatment means to control pleural effusion.
A pleuroperitoneal shunt is another palliative procedure that involves catheter placement, threading it under the patient's skin from the pleural to the peritoneal cavity. This is not a very popular palliative treatment option because of the possible obstruction of the catheter and seeding of tumor in various cavities.
The choice of treatment options for malignant mesothelioma is Dependant upon the patient's stage of the disease at diagnosis. Prompt recognition of symptoms and timely diagnosis are still requisite before these treatment options can be instituted.
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