Download DIFFUSE MALIGNANT MESOTHELIOMA

DIFFUSE MALIGNANT
MESOTHELIOMA
GENERAL THORACIC SURGERY
CHAPTER 65
Diffuse malignant pleural
mesothelioma
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Uncommon and lethal cancer.
Currently no standard treatment.
Asbestos exposure is major risk factors.
Important for thoracic surgeons to be
knowledgeable about mesothilioma –
Because they are often called on to make
the diagnosis and to recommend treatment.
Epidemiology — Asbestos
• Asbestos belongs to the family of silicate
fiber.
• Include two mineralogical groups:
Amphibole and Serpentine.
Amphibole fibers
• Narrow and straight fibers.
• Migrate through the lymphatics of
pulmonary parenchyma and accumulate in
interstitial space and subpleural region.
• Crocidolite asbestos（blue asbestos）-The most associate with malignant
mesothelioma.
Serpentine fibers
• Large, curly shaped fiber.
• do Not travel beyond the major airways.
• Chrysotile（white asbestos, the only
member of Serpentin） -- More associate
with lung cancer.
Diffuse malignant pleural
mesothelioma
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Peak age—6th decade.
Men.
Long latency period（at least 20 years）.
Incidence—men 15/million, women
3/million.
• Histology—Table 65-2.
Clinical presentation
• Nonspecific,
Chest pain, dyspnea, pleural effusion,
pericardial effusion, weight loss, cough,
anorexia, weakness, fever, hemoptysis.
• Horner’s syndrome.
• Spontaneous pneumothorax.
Clinical presentation
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Abnormal ECG– Sinus tachycardia (42%).
Echocardiographic findings.
No specific tumor marker.
Rise serum hyaluronan.
CA-125 (20%).
Radiographic appearance
• Chest-x ray— Variable and related to stage of
tumor.
• Large pleural effusion, pleural thickening, pleuralbased mass.
• Encasement of lung and obliteration of pleural
space.
• Involve pericardium and pericardial effusion.
• Chest wall invasion, invasion through diaphragm.
• CT— Most accurate noninvasive way to stage.
• PET scan.
Diagnosis
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Thoracentesis, cytology（positive rate 30-50%）.
Percutaneous pleural biopsy.
Thoracoscopy.
Open pleural biopsy.
AVOID Exploratory thoracotomy.
Bronchoscopy.
Meidastinoscopy.
Bone scans.
Staging
• Not an accurate, universally accepted
staging system.
• Butchart (1976). Table 65-3.
• TNM system. Table 65-4.
• Liver is the most common site of distal
metastasis, the contralateral lung is second.
Treatment
• Patient with malignant mesothelioma face a dual
problem— Control of the locoregional tumor
throughout the course of their disease, prevention
of distant metastases as late manifestation of their
cancer.
• Choice of treatment – Location and extent of he
tumor, the general medical condition of patient.
• Surgery, radiation, chemotherapy, immunotherapy,
supportive care.
Radiation therapy
• Difficult to evaluate the success of radiation
therapy as the only treatment.
• Usually given in conjunction with surgical
resection or chemotherapy.
• Limited by the volume of primary tumor that
invole entire hemithorax, proximity of the tumor
to many vital structures that intolerant high doses
of radiation.
• 4500 cGy.
• Adjuvant treatment after surgical resection of
gross tumor.
Chemotherapy
• Table 65-5.
• Combination treatment. Table 65-6.
• Response rate 30-40%
Immunotherapy
• Interferon– As antiproliferative effect on
mesothelioma cell line.
• Human interferon-α-2a combined with mitomycin
C.
• Interferon-γ – As an intrapleural treatment in
early-stage diaseas（40x106U infused into pleural
space twice weekly for 2 months）, 56% response.
• Intrapleural interleukin 2.
Intrapleural gene therapy
• Herpessimplex virus thymidine kinase
（HSVtk）gene– Transfer to tumor via
adenovirus.
• Administration of antiviral drug–
Ganciclovir– Led the tumor death.
Surgery
• Still the mainstay of treatment.
• Three operation–
(1). Extrapleural pneumonectomy.
（pleuropneumonectomy）
(2). Pleurectomy-decortication.
(3). Palliative limited pleurectomy.
Extrapleural pneumonectomy
• En bloc resection of pleura, lung, ipsilateral
hemidiaphragm, pericardium,
• Value– Controversial.
• Operative mortality 6- 30%.
• Preoperative CT, lung function, ventilationperfusion scan, cardiac function evaluate.
Pleurectomy-decortication
• Remove all gross pleural disease, without
removing underlying lung.
• Also remove hemidiaphragm and
pericardium.
Palliative limited pleurectomy
• Resection parietal pleura to control pleural
effusion.
• Thoracoscopy and talc poudrage — High
effective in controlling effusion.