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• W2010761400 abstract "Malignant mesothelioma of the pleura occurs primarily in individuals who were exposed to asbestos either in the workplace or home. The incidence of malignant mesothelioma is rising and, reflective of the malignancy's long latency period, is expected to continue to increase into the next century. Current treatment measures, including surgery, radiation therapy, chemotherapy, intrapleural therapy, and combined-modality therapies, have had varying impacts on survival. This paper explores current trends in the treatment of malignant pleural mesothelioma. Malignant mesothelioma of the pleura occurs primarily in individuals who were exposed to asbestos either in the workplace or home. The incidence of malignant mesothelioma is rising and, reflective of the malignancy's long latency period, is expected to continue to increase into the next century. Current treatment measures, including surgery, radiation therapy, chemotherapy, intrapleural therapy, and combined-modality therapies, have had varying impacts on survival. This paper explores current trends in the treatment of malignant pleural mesothelioma. Tumors of the pleura comprise a diverse and difficult group of diagnostic and management problems. The more commonly seen tumors metastatic to the pleura can originate from various different primary cancers. The rare primary tumors can present as either localized or diffuse tumors. The localized tumors tend to be benign whereas the diffuse tumors, primarily mesotheliomas, are usually highly malignant. The clinical approach to the management of malignant pleural mesothelioma has generated considerable interest. Malignant mesothelioma has been closely associated with asbestos exposure ever since it was reported in 1960 by Wagner et al1Wagner JC Sleggs EA Marchand P Diffuse pleural mesothelioma and asbestos in the North Western Cape Province.Br J Ind Med. 1960; 17: 260-271PubMed Google Scholar and subsequently confirmed by others throughout the world.2Fowler PBS Sloper JC Warner EC Exposure to asbestos and mesothelioma of the pleura.BMJ. 1964; 2: 211-213Crossref PubMed Google Scholar, 3Newhouse ML Thompson H Mesothelioma of pleura and peritoneum following exposure to asbestos in the London area.Br J Ind Med. 1993; 50: 769-778PubMed Google Scholar, 4Selikoff IJ Churg J Hammond EC Asbestos exposure and neoplasia.JAMA. 1964; 188: 122-126Crossref Scopus (343) Google Scholar There may be 3,000 or more cases of mesothelioma seen annually in the United States.5Walker AM Loughlin JE Freidlander ER et al.Projections of asbestos-related disease 1980-2009.J Occup Med. 1983; 25: 409-425PubMed Google Scholar,6Enterline PE Henderson VL Geographic patterns for female pleural mesothelioma deaths for 50 states.J Natl Cancer Inst. 1987; 79: 31-37PubMed Google Scholar The exact incidence and death rate, however, can be difficult to ascertain since in the past mesothelioma was often reported as lung cancer. Mesothelioma has probably increased in incidence7Spirtas R Beebe GW Connelly RR et al.Recent trends in mesothelioma incidence in the United States.Am J Ind Med. 1986; 9: 397-407Crossref PubMed Google Scholar,8Connelly RR Spirtas R Myers MH et al.Demographic patterns for mesothelioma in the United States.J Natl Cancer Inst. 1987; 78: 1053-1060PubMed Google Scholar due in part to the increased use of asbestos during and following World War II. The incidence is expected to continue to rise into the next century, reflecting the large population of 8 million or more who were asbestos-exposed.5Walker AM Loughlin JE Freidlander ER et al.Projections of asbestos-related disease 1980-2009.J Occup Med. 1983; 25: 409-425PubMed Google Scholar,6Enterline PE Henderson VL Geographic patterns for female pleural mesothelioma deaths for 50 states.J Natl Cancer Inst. 1987; 79: 31-37PubMed Google Scholar,8Connelly RR Spirtas R Myers MH et al.Demographic patterns for mesothelioma in the United States.J Natl Cancer Inst. 1987; 78: 1053-1060PubMed Google Scholar On the East and West Coasts of the United States, where shipbuilding industries once flourished, malignant mesothelioma can be linked to asbestos exposure in nearly 80% of cases. Correlation with asbestos exposure has not been as high in the midwest.9Vogelzang NJ Schultz SM Iannucci AM et al.Malignant mesothelioma: the University of Minnesota Medical School experience.Cancer. 1984; 53: 377-383Crossref PubMed Google Scholar Reflecting workplace exposure, malignant mesothelioma is seen more frequently in men than women, and the median age at presentation is greater than 60 years, reflecting a long period of latency. Mesothelioma has also been reported among family members of asbestos workers and in young adults as a consequence of household or neighborhood exposure.1Wagner JC Sleggs EA Marchand P Diffuse pleural mesothelioma and asbestos in the North Western Cape Province.Br J Ind Med. 1960; 17: 260-271PubMed Google Scholar,10Anderson HA Lilis R Daum SM et al.Household-contact asbestos neoplastic risk.Ann NY Acad Med. 1976; 271: 311-323Crossref PubMed Google Scholar, 11Li FP Lokich J Familial mesothelioma after intense asbestos exposure at home.JAMA. 1978; 240: 467Crossref PubMed Google Scholar, 12Vianna NJ Polan AK Non-occupational exposure to asbestos and malignant mesothelioma in females.Lancet. 1978; 1: 1061-1063Abstract PubMed Google Scholar, 13Risberg B Nickels J Wagermark J Familial clustering of malignant mesothelioma.Cancer. 1980; 45: 2422-2427Crossref PubMed Google Scholar Thus, even relatively mild exposure to asbestos increases the risk of mesothelioma. The direct application of asbestos fibers onto the pleural surfaces of experimental animals is known to produce mesotheliomas, and some fiber types are more potent in this regard than others.14Suzuki Y Malignant mesothelioma induced by asbestos and zeolite in the mouse peritoneum [abstract].Proc Am Assoc Cancer Res. 1983; 24: 240Google Scholar The thin, rodlike amphiboles are believed to be more carcinogenic than the chrysotile asbestos fibers, although contamination of chrysotile fibers with amphibole fiber forms is common.15McDonald JC Armstrong B Case B et al.Mesothelioma and asbestos fiber type: evidence from lung tissue analyses.Cancer. 1989; 63: 1544-1547Crossref PubMed Google Scholar, 16Gibbs AR Griffiths DM Pooley FD et al.Comparison of fibre types and size distributions in lung tissues of paraoccupational and occupational cases of malignant mesothelioma.Br J Ind Med. 1990; 47: 621-626PubMed Google Scholar, 17Rogers AJ Leigh J Berry G et al.Relationship between lung asbestos fiber type and concentration and relative risk of mesothelioma: a case-control study.Cancer. 1991; 67: 1912-1920Crossref PubMed Google Scholar The carcinogenic effects of asbestos fibers are believed to be related to their size and shape rather than their chemical composition.18Timbrell V Physical factors as etiological mechanisms.in: Bogovski P Gilson JC Timbrell V Biological effects of asbestos. IARC Sci Publ (8), Lyon, France1973: 295-304Google Scholar Asbestos fibers separate into minute fragments. These small inhaled fibers are not easily cleared in the upper airways; they tend to migrate through the distal endothelium into the interstitial tissues, where they penetrate the visceral pleura.19Craighead JE Mossman BT The pathogenesis of asbestos-associated disease.N Engl J Med. 1992; 306: 1446-1455Crossref Google Scholar The fibers are then ingested by macrophages, which become damaged in the process, thereby leaking enzymes, cytokines, and superoxide radicals. The asbestos fibers thus produce an inflammatory and fibrotic reaction.20Rom WN Travis WD Brody AR Cellular and molecular basis of the asbestos-related diseases.Am Rev Respir Dis. 1991; 143: 408-422Crossref PubMed Google Scholar The fibers can also carry absorbed carcinogens, which may further contribute to the carcinogenic process. Other possible causal factors include radiation therapy,21Antman KH Corson JM Li FP et al.Malignant mesothelioma following radiation exposure.J Clin Oncol. 1983; 1: 695-700Crossref PubMed Google Scholar, 22Antman K Pomfret E Aisner J et al.Peritoneal mesothelioma: natural history and response to chemotherapy.J Clin Oncol. 1983; 1: 386-391Crossref PubMed Scopus (62) Google Scholar, 23Jagirdar J Frydman C Sakurai H et al.Mesothelial papillary proliferation of the pleura associated with radiation therapy: does it have a role in the pathogenesis of mesothelioma.Mt Sinai J Med. 1989; 56: 147-179PubMed Google Scholar, 24Kawashima A Libshitz HI Lukeman JM Radiation-induced malignant pleural mesothelioma.Can Assoc Radiol J. 1990; 41: 384-386PubMed Google Scholar, 25Lerman Y Learman Y Schachter P et al.Radiation associated malignant pleural mesothelioma.Thorax. 1991; 46: 463-464Crossref PubMed Google Scholar extravasated thoratrast,26Maurer R Egloff B Malignant peritoneal mesothelioma after cholangiography with thorotrast.Cancer. 1975; 36: 1381-1385Crossref PubMed Google Scholar and other fibers such as zeolite and erionite with physical properties similar to asbestos.14Suzuki Y Malignant mesothelioma induced by asbestos and zeolite in the mouse peritoneum [abstract].Proc Am Assoc Cancer Res. 1983; 24: 240Google Scholar,27Artvinli M Baris YI Malignant mesothelioma in a small village in the Anatolian region of Turkey: an epidemiologic study.J Natl Cancer Inst. 1979; 63: 17-22PubMed Google Scholar, 28Rohl AN Langer AM Moncure G et al.Endemic pleural disease associated with exposure to mixed fibrous dust in Turkey.Science. 1982; 216: 518-520Crossref PubMed Google Scholar, 29Gardner MJ Saracci R Effects on health of non-occupational exposure to airborne mineral fibres.in: Bignon J Peto J Saracci R Nonoccupational exposure to mineral fibres. IARC Sci Publ (90), Lyon, France1989: 375-397Google Scholar Most often signs and symptoms associated with pleural effusion or nonpleuritic chest pain induce patients to seek medical attention. Fever, sweats, weight loss, and easy fatigability are also common presenting complaints.30Antman KH Clinical presentation and natural history of benign and malignant mesothelioma.Semin Oncol. 1981; 8: 313-320PubMed Google Scholar Thrombocytosis,31Wojtukiewicz MZ Zacharski RL Memoli VA et al.Absence of components of coagulation and fibrinolysis pathways in situ in mesothelioma.Thromb Res. 1989; 55: 279-284Abstract Full Text PDF PubMed Google Scholar,32De Pangher Manzini V Brollo A et al.Thrombocytosis in malignant pleural mesothelioma.Tumori. 1990; 76: 576-578PubMed Google Scholar disseminated intravascular coagulation, thrombophlebitis, pulmonary emboli, and Coombs positive hemolytic anemia have also been reported.30Antman KH Clinical presentation and natural history of benign and malignant mesothelioma.Semin Oncol. 1981; 8: 313-320PubMed Google Scholar The median durations of survival for patients with malignant mesothelioma have ranged from 4 to 18 months. Better survival is associated with younger age,33Chahinian AP Pajak TF Holland J et al.Diffuse malignant mesothelioma: prospective evaluation of 69 patients.Ann Intern Med. 1982; 96: 746-755Crossref PubMed Google Scholar,34Antman K Shemin R Ryan L et al.Malignant mesothelioma: prognostic variables in a registry of 180 patients: the Dana-Farber Cancer Institute and Brigham and Women's Hospital experience over two decades 1965-1985.J Clin Oncol. 1988; 6: 147-153Crossref PubMed Google Scholar good performance status,30Antman KH Clinical presentation and natural history of benign and malignant mesothelioma.Semin Oncol. 1981; 8: 313-320PubMed Google Scholar early stage,35Ruffie P Feld R Minkin S et al.Diffuse malignant mesothelioma of the pleura in Ontario and Quebec: a retrospective study of 332 patients.J Clin Oncol. 1989; 7: 1157-1168Crossref PubMed Google Scholar epithelial histology,33Chahinian AP Pajak TF Holland J et al.Diffuse malignant mesothelioma: prospective evaluation of 69 patients.Ann Intern Med. 1982; 96: 746-755Crossref PubMed Google Scholar,36Schildge J Kaiser D Henss H et al.Prognostic factors in diffuse malignant mesothelioma of the pleura.Pneumologie. 1989; 43: 660-664PubMed Google Scholar lack of chest pain,33Chahinian AP Pajak TF Holland J et al.Diffuse malignant mesothelioma: prospective evaluation of 69 patients.Ann Intern Med. 1982; 96: 746-755Crossref PubMed Google Scholar,37Hulks G Thomas JS Waclawski E Malignant pleural mesothelioma in Western Glasgow 1980-86.Thorax. 1989; 44: 496-500Crossref PubMed Google Scholar and a normal platelet count.33Chahinian AP Pajak TF Holland J et al.Diffuse malignant mesothelioma: prospective evaluation of 69 patients.Ann Intern Med. 1982; 96: 746-755Crossref PubMed Google Scholar, 34Antman K Shemin R Ryan L et al.Malignant mesothelioma: prognostic variables in a registry of 180 patients: the Dana-Farber Cancer Institute and Brigham and Women's Hospital experience over two decades 1965-1985.J Clin Oncol. 1988; 6: 147-153Crossref PubMed Google Scholar, 35Ruffie P Feld R Minkin S et al.Diffuse malignant mesothelioma of the pleura in Ontario and Quebec: a retrospective study of 332 patients.J Clin Oncol. 1989; 7: 1157-1168Crossref PubMed Google Scholar Roentgenograms can show evidence of asbestos exposure such as pleural plaques or calcifications in the diaphragm, although asbestosis is not a necessary precondition. Recently, asymptomatic individuals were identified with an incidental effusion on a routine chest x-ray film,38Antman KH Malignant mesothelioma.N Engl J Med. 1980; 303: 200-202Crossref PubMed Google Scholar leading to diagnosis at an earlier stage. A CT scan of the chest provides the best preoperative assessment of the extent of disease.39Mirvis S Dutcher JP Haney PJ et al.CT of malignant pleural mesothelioma.Am J Roentgenol. 1983; 140: 665-670Crossref PubMed Google Scholar Thickening of the pleura with involvement of thein-terlobar fissures and atelectasis are the earliest evidence observed on CT scans.24Kawashima A Libshitz HI Lukeman JM Radiation-induced malignant pleural mesothelioma.Can Assoc Radiol J. 1990; 41: 384-386PubMed Google Scholar,40Alexander E Clark R Colley D et al.CT of malignant pleural mesothelioma.Am J Roentgenol. 1981; 137: 287-291Crossref PubMed Google Scholar, 41Kreel L Computed tomography in mesothelioma.Semin Oncol. 1981; 8: 302-312PubMed Google Scholar, 42Grant DC Seltzer SE Antman KH et al.Computed tomography of malignant pleural mesothelioma.J Comput Assist Tomogr. 1983; 7: 626-632Crossref PubMed Google Scholar, 43Leung AN Muller NL Miller RR CT in differential diagnosis of diffuse pleural disease.Am J Roentgenol. 1990; 154: 487-492Crossref PubMed Google Scholar In early disease, discreet nodules and coalescent plaques are seen on the visceral and parietal pleura at the time of thoracoscopy or surgery. Early pleural effusions tend to become progressive rinds of tumor that encase the lung as they grow.44Elmes PC Simpson M The clinical aspects of mesothelioma.Q J Med. 1976; 45: 427-449PubMed Google Scholar As the disease progresses, there is also loss of diaphragmatic and intercostal muscle movement, chest contraction, and scoliosis. Mesotheliomas tend to grow and invade locally until late in their natural history; dysphagia, chest pain, cord compression, plexopathy, Horner's syndrome, or superior vena cava syndrome can arise from their extension into the esophagus, ribs, vertebrae, nerves, and superior vena cava.30Antman KH Clinical presentation and natural history of benign and malignant mesothelioma.Semin Oncol. 1981; 8: 313-320PubMed Google Scholar,38Antman KH Malignant mesothelioma.N Engl J Med. 1980; 303: 200-202Crossref PubMed Google Scholar The tumor also tends to grow along drainage and thoracotomy tracts.44Elmes PC Simpson M The clinical aspects of mesothelioma.Q J Med. 1976; 45: 427-449PubMed Google Scholar, 45Gordon W Antman K Breenberger J et al.Radiation therapy in the management of patients with mesothelioma.Int J Radiat Oncol Biol Phys. 1982; 8: 19-25Abstract Full Text PDF PubMed Scopus (0) Google Scholar, 46Boutin C Viallat JR Zandwijk NV et al.Activity of intrapleural recombinant gamma-interferon in malignant mesothelioma.Cancer. 1991; 67: 2033-2037Crossref PubMed Scopus (100) Google Scholar Extension into the pulmonary parenchyma, chest wall, medastinum, and diaphragm are common as the disease progresses (Fig 1). Mediastinal and cervical lymph nodes may also become involved. Symptomatically, as the disease advances, the patient typically complains of fatigue and dyspnea that is out of proportion to the chest x-ray findings due to the arteriovenous shunting of blood in the poorly aerated, trapped lung. Most patients undergo repeated diagnostic and therapeutic thoracenteses with negative or indeterminant cytologic findings despite having active tumors. Diagnosis based on a needle biopsy is often very difficult because of the small specimens obtained. Immunocytochemistry and electron microscopy can be helpful in this situation,47Said J Nash G Lee M Keratin proteins and carcinoembryonic antigen in lung carcinoma: an immunoperoxidase study of 54 cases with ultrastructural correlations.Hum Pathol. 1983; 14: 70-76Abstract Full Text PDF PubMed Google Scholar,48Corson JM Pinkus GSS Mesothelioma: profile of keratin proteins and carcinoembryonic antigen; an immuno-peroxidase study of 20 cases and comparison with pulmonary adenocarcinomas.Am J Pathol. 1982; 108: 80-88PubMed Google Scholar but larger tissue samples are usually required for these procedures.49Suzuki Y Churg C Kannerstein M Ultrastructure of human malignant diffuse mesothelioma.Am J Pathol. 1976; 85: 241-262PubMed Google Scholar, 50Bolen JW Thorning D Mesotheliomas: a light and electron microscopical study concerning the histogenic relationships between the epithelial and the mesenchymal variants.Am J Surg Pathol. 1980; 4: 451-464Crossref PubMed Google Scholar, 51Warhol MJ Hickey WF Corson JM Malignant mesothelioma: ultrastructural distinction from adenocarcinoma.Am J Surg Pathol. 1982; 6: 307-314Crossref PubMed Google Scholar Newer techniques such as thoracoscopy and pleuroscopy have been used with considerable success in obtaining adequate tissue samples.52Boutin C Rey F Thoracoscopy in pleural malignant mesothelioma: a prospective study of 188 patients: Part 1 Diagnosis.Cancer. 1993; 72: 389-393Crossref PubMed Google Scholar Boutin et al46Boutin C Viallat JR Zandwijk NV et al.Activity of intrapleural recombinant gamma-interferon in malignant mesothelioma.Cancer. 1991; 67: 2033-2037Crossref PubMed Scopus (100) Google Scholar,52Boutin C Rey F Thoracoscopy in pleural malignant mesothelioma: a prospective study of 188 patients: Part 1 Diagnosis.Cancer. 1993; 72: 389-393Crossref PubMed Google Scholar showed that thoracoscopy can be nearly 95% as accurate as an open thoracotomy performed for diagnostic purposes. Generous samples are usually taken for diagnosis, and samples of uninvolved lung are sometimes obtained for counting asbestos fibers.53Churg A Fiber counting and analysis in the diagnosis of asbestos-related disease.Hum Pathol. 1982; 13: 381-392Abstract Full Text PDF PubMed Google Scholar Three histologic subtypes of mesothelioma are usually defined: epithelial, sarcomatous, and mixed (epithelial/sarcomatous).54Kannerstein M Churg J Magner D Histochemistry in the diagnosis of malignant mesothelioma.Ann Clin Lab Sci. 1973; 3: 207-211PubMed Google Scholar,55Kannerstein M Churg J A critique of the criteria for the diagnosis of diffuse malignant mesothelioma.Mt Sinai J Med. 1977; 44: 485-497PubMed Google Scholar Most mesotheliomas occur with the epithelial subtype, and these have variously been described to show papillary, solid, tubular, or vacuolated patterns. The sarcomatous form appears similar to a fibrosarcoma with predominantly spindle- or ovoid-shaped cells. The mixed or biphasic form demonstrates both epithelial and sarcomatous elements, and the finding of both elements is virtually diagnostic of malignant mesothelioma. Metastatic adenocarcinoma originating from lung, breast, ovarian, stomach, kidney, or prostate cancers can sometimes be difficult to distinguish grossly and histologically from the epithelial form of mesothelioma. In fact, malignant mesothelioma was not recognized as a unique entity until the late 1930s, due in part to these difficulties.56Robertson HE Endothelioma of the pleura.J Cancer Res. 1924; 8: 317-324Google Scholar Today, histochemistry, immunohistochemistry, and electron microscopy can usually provide this distinction. Since it is rare in mesothelioma, a positive mucicarmine stain is very suggestive of adenocarcinoma. Periodic acid-Schiff stain (PAS) before and after diastase digestion, alcian blue stain, and colloidal-iron stains can also be helpful in distinguishing mesothelioma from metastatic disease.54Kannerstein M Churg J Magner D Histochemistry in the diagnosis of malignant mesothelioma.Ann Clin Lab Sci. 1973; 3: 207-211PubMed Google Scholar,57Corson J Pathology of malignant mesothelioma.in: Antman K Aisner J Asbestos related malignancy. Grune and Stratton, Orlando, Fla1987: 179-200Google Scholar Electron microscopy is considered by most to be the reference method for defining the diagnosis of malignant mesothelioma.49Suzuki Y Churg C Kannerstein M Ultrastructure of human malignant diffuse mesothelioma.Am J Pathol. 1976; 85: 241-262PubMed Google Scholar, 50Bolen JW Thorning D Mesotheliomas: a light and electron microscopical study concerning the histogenic relationships between the epithelial and the mesenchymal variants.Am J Surg Pathol. 1980; 4: 451-464Crossref PubMed Google Scholar, 51Warhol MJ Hickey WF Corson JM Malignant mesothelioma: ultrastructural distinction from adenocarcinoma.Am J Surg Pathol. 1982; 6: 307-314Crossref PubMed Google Scholar The characteristic features on electron microscopy for the epithelial form include numerous long, slender, branching surface microvilli, desmosomes, abundant tonofilaments, and intracellular lumen formation on polygonal cells.49Suzuki Y Churg C Kannerstein M Ultrastructure of human malignant diffuse mesothelioma.Am J Pathol. 1976; 85: 241-262PubMed Google Scholar,50Bolen JW Thorning D Mesotheliomas: a light and electron microscopical study concerning the histogenic relationships between the epithelial and the mesenchymal variants.Am J Surg Pathol. 1980; 4: 451-464Crossref PubMed Google Scholar Elongated nuclei and abundant rough endoplasmic reticulin are found in the sarcomatous subtype. Although the Butchart staging system is the one most widely used in pleural mesothelioma (Table 1), it does not uniformly predict survival outcomes or offer adequate description of the degree of chest wall invasion or lymph node involvement, the latter of which has been shown to have prognostic significance.59Sugarbaker DJ Strauss GM Lynch TJ et al.Node status has prognostic significance in the multimodality therapy of diffuse, malignant mesothelioma.J Clin Oncol. 1993; 11: 1172-1178Crossref PubMed Scopus (193) Google Scholar Chahinian60Chahinian AP Therapeutic modalities: malignant pleural mesothelioma.in: Chretien J Hirsch A Diseases of the pleura. Masson, New York1983: 224-236Google Scholar and subsequently the International Union Against Cancer (UICC)61Rusch VS Ginsberg RJ New concepts in the staging of mesotheliomas.in: Deslauriers J Lacquet LK International trends in general thoracic surgery. CV Mosby, St Louis1990: 336-343Google Scholar developed a TNM-based staging system that considers the extent of local invasion and the involvement of regional lymph nodes (Table 2). In the UICC system, the translation of TNM categories into stages I-IV disease is organized in a manner similar to that used for non-small cell lung cancer. However, the data to associate the degree of local tumor, the impact of regional nodal involvement, organ invasion, etc, with long-term survival have not, as yet, been well established. For this reason, a new revision of the TNM system is under development.Table 1Butchart Staging ClassificationStageITumor confined within the capsule of the parietal pleural, involving only ipsilateral pleura, lung, pericardium, and diaphragmIITumor invading chest wall or involving mediastinal structures, such as esophagus, heart, opposite pleuraIIITumor penetrating diaphragm to involve peritoneum; involvement of opposite pleura and lymph nodes outside the chestIVDistant bloodborne metastases Open table in a new tab Table 2UICC Staging of Mesothelioma*Staging based solely on clinical measures is designated cTNM. Staging based on pathologic information is designated pTNM. IT1N0M0T2N0M0 IIT1N1M0T2N1M0 IIIT3N0M0T3N1M0T1N2M0T2N2M0T3N2M0 IVAny TN3M0T4, any N, M0Any T and N, MlT-Primary Tumor and Extent TxPrimary tumor cannot be assessed T0Evidence of primary tumor T1Primary tumor limited to ipsilateral, parietal, and/or visceral pleura T2Tumor invades any of the following: ipsilateral lung, endothoracic fascia, diaphragm, pericardium T3Tumor invades any of the following: ipsilateral chest wall muscle, ribs, mediastinal organs or tissues T4Tumor extends to any of the following: contralateral pleura or lung by direct extension, peritoneum or intraabdominal organs by direct extension, cervical tissuesN-Lymph Nodes NxRegional lymph nodes cannot be assessed NONo regional lymph node metastases N1Metastases in ipsilateral bronchopulmonary of hilar lymph nodes N2Metastases in ipsilateral mediastinal lymph nodes N3Metastases in contralateral mediastinal, internal mammary, supraclavicular, or scalene lymph nodesM-Metastases MxPresence of distant metastases cannot be assessed M0No (known) distant metastases MlDistant metastases present* Staging based solely on clinical measures is designated cTNM. Staging based on pathologic information is designated pTNM. Open table in a new tab While surgical procedures to obtain diagnostic material are of critical importance, the role of surgery as a therapeutic manipulation remains controversial. Although pleurectomy can reduce the recurrence of effusions,62Ruffie P Feld R Minkin S et al.Diffuse malignant mesothelioma of the pleura in Ontario and Quebec: a retrospective study of 331 patients.J Clin Oncol. 1990; 45: 40-42Google Scholar,63Brancatisano RR Joseph MG McCaughan BC Pleurectomy for mesothelioma.Med J Aust. 1991; 154: 455-457Crossref PubMed Google Scholar surgery has little role in the palliative management of mesothelioma. In the past, most patients presented with locally advanced disease for which aggressive surgery was not a realistic option. Today, however, with the risk of disease in asbestos-exposed individuals well recognized, many patients are diagnosed with earlier stages of mesothelioma, and such patients may have a longer survival. Thus, surgical excision may be a reasonable approach in patients with disease confined to the pleural space. Two surgical procedures have been described as potentially therapeutic: decortication (pleurectomy) and extrapleural pneumonectomy. With pleurectomy, the pleura and pericardium are stripped from the apex of the lung to the diaphragm. Since the tumor grows from the pleura into adjacent tissues and lung (Fig 1), a clean separation of lung and visceral pleura is often difficult. Operative mortality from pleurectomy is usually low (1 to 2%), and complications include bronchopleural fistulae, hemorrhage, and subcutaneous emphysema. Various studies using this approach have reported median survivals ranging from 6.7 to 21 months (Table 3).62Ruffie P Feld R Minkin S et al.Diffuse malignant mesothelioma of the pleura in Ontario and Quebec: a retrospective study of 331 patients.J Clin Oncol. 1990; 45: 40-42Google Scholar, 63Brancatisano RR Joseph MG McCaughan BC Pleurectomy for mesothelioma.Med J Aust. 1991; 154: 455-457Crossref PubMed Google Scholar, 64Lewis RJ Sisler GE Mackenzie JW Diffuse mixed malignant pleural mesothelioma.Ann Thorac Surg. 1981; 3: 153-160Google Scholar, 65McCormack P Nagasaki F Hilaris BS et al.Surgical treatment of pleural mesothelioma.J Thorac Cardiovasc Surg. 1982; 84: 834-842Abstract Full Text PDF PubMed Google Scholar, 66Law MR Hodson ME Turner-Warwick M Malignant mesothelioma of the pleura: clinical aspects and symptomatic treatment.Eur J Respir Dis. 1984; 65: 162-168PubMed Google Scholar, 67Law MR Gregor A Hodson ME et al.Malignant mesothelioma of the pleura: a study of 52 untreated patients.Thorax. 1984; 39: 255-259Crossref PubMed Google Scholar, 68Hilaris BS Dattatreyudu NK Wong E et al.Pleurectomy and intraoperative brachytherapy and postoperative radiation in the management of malignant pleural mesothelioma.Int J Radiat Oncol Biol Phys. 1984; 10: 325-331Abstract Full Text PDF PubMed Scopus (0) Google Scholar, 69DaValle MJ Faber LP Kittle CF Extrapleural pneumonectomy for diffuse, malignant mesothelioma.Ann Thorac Surg. 1986; 42: 612-618Abstract Full Text PDF PubMed Google Scholar, 70Wanebo HJ Martini N Melamed MR et al.Pleural mesothelioma.Cancer. 1986; 38: 2481-2488Crossref Scopus (81) Google Scholar, 71Achatzy R Beba W Ritschler R et al.The diagnosis, therapy and prognosis of diffuse malignant mesothelioma.Eur J Cardiothorac Surg. 1989; 3: 445-447Crossref PubMed Google Scholar, 72Rusch VW Pleurectomy/decortication and adjuvant therapy for malignant mesothelioma.Chest. 1993; 103: 382S-384SAbstract Full Text Full Text PDF PubMed Google Scholar, 73Aisner J Belani CP Antman KH Pleura and mediastinum.in: Abeloff MD Armitage J Clinical oncology. Churchill Livingstone International, New York1995: 1153-1188Google Scholar Investigators at Memorial Sloan-Kettering Cancer Center (MSKCC) have used pleurectomy combined with either external beam with or without interstitial irradiation or with postoperative intrapleural therapies and irradiation.65McCormack P Nagasaki F Hilaris BS e" @default.
• W2010761400 created "2016-06-24" @default.
• W2010761400 creator A5054371540 @default.
• W2010761400 date "1995-06-01" @default.
• W2010761400 modified "2023-10-06" @default.
• W2010761400 title "Current Approach to Malignant Mesothelioma of the Pleura" @default.
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