Diagnosis and treatment of pleural mesothelioma

Our plain-English summary of Diagnosis and treatment of pleural mesothelioma, by V.W. Rusch (Seminars in Surgical Oncology, 1990).

The study

• Author: V.W. Rusch
• Journal: Seminars in Surgical Oncology
• Published: 1990;6(5):279-85
• Type of article: Review
• Cited by: 24 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Pleural mesotheliomas are uncommon tumors. They can be broadly classified as localized and diffuse. The localized form is a non-epithelial neoplasm that occurs as commonly in women as in men and is not related to asbestos exposure. It is usually asymptomatic, and is occasionally associated with paraneoplastic syndromes. Localized mesotheliomas arise more frequently from the visceral than from the parietal or mediastinal pleura. The long-term outcome of these tumors is determined mainly by their clinical presentation, and by whether or not they can be completely resected. Diffuse pleural mesotheliomas are invariably malignant. They are clearly related to asbestos exposure, and are far more common in men than in women. Histologically, they are completely or partially epithelial tumors. Diffuse mesotheliomas present with dyspnea, chest pain, and weight loss and are not associated with paraneoplastic syndromes. Distinguishing malignant mesothelioma from metastatic adenocarcinoma can be difficult and usually requires a large tissue biopsy on which immunohistochemistry and electron microscopy can be performed. The management of diffuse malignant mesothelioma remains controversial. Treatment appears to prolong survival which ranges from 6 to 12 months with supportive care alone. Surgical resection, either with extrapleural pneumonectomy or by pleurectomy/decortications remains the mainstay of treatment because of the relative ineffectiveness of radiation and chemotherapy. Surgical resection alone, however, is inadequate, so most current treatment regimens combine operation with radiation and/or chemotherapy. Even with aggressive multimodality treatment, the median survival currently ranges from 18 to 24 months. A better understanding of prognostic factors, a better staging system, and innovative treatment strategies are desperately needed in this disease.

In plain English

This article was a narrative review by a surgeon at Memorial Sloan-Kettering Cancer Center. It summarized published work on diagnosing and treating pleural mesothelioma and reported no new study. The author described two forms. The localized form had no known link to asbestos, and patients in whom it could not be completely removed usually died within 2 years. The diffuse form was malignant. The author called asbestos its single most important risk factor and, citing other studies, said men developed it 6-7 times more often than women. Citing a published series, the author reported that biopsies taken by thoracoscopy were diagnostic in over 80% of cases in patients whose pleural space was still totally or partially free. Supportive care alone probably gave a median survival of 6 to 12 months. Removing the lung and pleura carried a mortality of 10 to 30%, compared with 2% or less for pleurectomy and decortication. The author concluded that operation plus radiation and/or chemotherapy seemed to give a modest improvement in median survival, and that carefully designed multi-institutional trials were needed.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Narrative review of published literature (no new patient data)
• Who was studied: Published reports on patients with localized and diffuse pleural mesothelioma, including Memorial Sloan-Kettering's Thoracic Service experience of 150 cases from 1972 to 1985, of which 41 were considered localized
• Exposure: Asbestos, described as the main risk factor for diffuse malignant mesothelioma. The review discussed amphibole fibers (crocidolite, amosite, tremolite, anthophyllite, actinolite) and the serpentine fiber chrysotile, as well as erionite, talc contaminated by asbestos, and less common risk factors. The localized form was described as not linked to asbestos.
• Main results:
  • Localized mesothelioma: patients in whom complete surgical removal was not achieved usually died within 2 years (as reported from the literature)
  • Citing other work, the review reported US incidence of diffuse malignant mesothelioma of 1 to 2 per million population per year before 1960, rising to 15 per million, or about 3,000 cases per year
  • Citing other work, men developed diffuse malignant mesothelioma 6-7 times more frequently than women
  • Citing other work, up to 40% of patients who develop mesothelioma have no known asbestos exposure or other obvious risk factor
  • Citing a published series, in patients who still had a totally or partially free pleural space, biopsies obtained by thoracoscopy were diagnostic in over 80% of cases. If the pleural space was obliterated by adhesions or tumor, biopsies via a limited thoracotomy were diagnostic in over 90% of cases.
  • Combination chemotherapy response rates of 30 to 40% in small single-institution studies fell to only about 15% in later cooperative group trials
  • Pleuropneumonectomy (extrapleural pneumonectomy) carried a mortality of 10 to 30%. In a Lung Cancer Study Group study, only 25% of patients (20/83) met the criteria for this operation.
  • Pleurectomy and decortication was reported as feasible in about 90% of patients with disease limited to one side of the chest, with a mortality of 2% or less
  • In a 1984 Memorial Sloan-Kettering report by Hilaris et al., the median survival of 41 patients treated with pleurectomy, intraoperative radioactive implant and postoperative external radiation was 21 months
  • In a pilot study of 10 patients given pleurectomy and decortication with intrapleural cisplatin and then systemic cisplatin and mitomycin, median survival exceeded 17 months
  • Across multiple series, epithelial cell type seemed to be the most consistent prognostic indicator
• The authors' conclusion: The author concluded that operation plus radiation and/or chemotherapy seems to give a modest improvement in median survival, and that diffuse mesothelioma needs carefully designed multi-institutional clinical trials
• Limitations the authors state:
  • The author stated that prognostic factors are poorly understood because most published series are retrospective, are small or drawn from many institutions, and do not stage or follow patients in a uniform way
  • The author stated that none of the proposed staging systems had been verified by careful clinicopathologic correlation

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Neoplasm, Asbestos Exposure, Localized Malignant Mesothelioma, Pleura, Mesothelioma, Dyspnea, Adenocarcinoma.

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