Multimodality treatment of diffuse malignant pleural mesothelioma*
Section snippets
Clinical presentation
The typical DMPM patient who presents for surgical evaluation is a male over the age of 55 (3:1 male-to-female ratio) with unilateral disease (95%). DMPM tends to be right-sided (60%).3 Patients usually report symptoms related to the presence of a pleural effusion, such as dyspnea, cough, chest pain that may be nonpleuritic in nature, and occasionally fever, night sweats, fatigue, and weight loss.3 Unrelenting local spread with invasion into the chest wall, the lung and its fissures, the
Radiation therapy
Unresected diffuse malignant pleural mesothelioma is difficult to treat with radiation alone. Unlike other tumors, mesothelioma is a diffuse process, and a much larger radiation field is required compared to other thoracic malignancies. Numerous vital structures limit the radiation dose that can be safely delivered (lung, 20 Gy; liver, 30 Gy; spinal cord, 45 Gy; heart, 45 Gy; and esophagus, 45 to 50 Gy).18 The Joint Center for Radiation Therapy in Boston conducted a review of mesothelioma
Multimodality treatment
Several multimodality approaches have been evaluated for the treatment of DMPM due to the failure of single modality therapy to affect survival. Cytoreductive surgery (P/D or EPP) has been incorporated with intrapleural or external-beam radiotherapy, intrapleural and/or systemic immunotherapy, and chemotherapy. Efforts have mainly focused on improving local control of this disease.
Conclusions
DMPM remains a difficult disease to treat. Like any other malignancy, early diagnosis is essential. Treatment must be tailored according to stage and histologic subtype. Overall, there is a trend in these studies for improved survival in patients with early stage disease. Patients with advanced disease have not enjoyed this benefit with multimodality regimens. The Brigham/DFCI approach of EPP and adjuvant chemoradiation with a median survival of 51 months is the longest survival of any reported
Acknowledgements
The authors thank Mary S. Visciano for editorial assistance
References (42)
- et al.
The role of cytologic evaluation of pleural fluid in the diagnosis of malignant mesothelioma
Chest
(1997) - et al.
The role of closed pleural needle biopsy in the diagnosis of malignant mesothelioma of the pleura
Chest
(1992) - et al.
Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: Results in 183 patients
J Thorac Cardiovasc Surg
(1999) - et al.
Positron emission tomography with f18-fluorodeoxyglucose in the staging and preoperative evaluation of malignant pleural mesothelioma
J Thorac Cardiovasc Surg
(2000) A proposed new international TNM staging system for malignant pleural mesothelioma from the International Mesothelioma Interest Group
Lung Cancer
(1996)Deterioration in lung function following hemithorax irradiation for pleural mesothelioma
Int J Radiat Oncol Biol Phys
(1991)- et al.
Radiation therapy in the management of patients with mesothelioma
Int J Radiat Oncol Biol Phys
(1982) - et al.
Prevention of malignant seeding after invasive diagnostic procedures in patients with pleural mesothelioma. A randomized trial of local radiotherapy
Chest
(1995) - et al.
Sclerotherapy for malignant pleural effusions: A prospective randomized trial of bleomycin vs doxycycline with small-bore catheter drainage
Chest
(1998) - et al.
A review of chemotherapy trials for malignant mesothelioma
Chest
(1998)
Extrapleural pneumonectomy in the setting of a multimodality approach to malignant mesothelioma
Chest
Aggressive multimodality therapy for malignant pleural mesothelioma
Ann Thorac Surg
Intrapleural perfusion hyperthermo-chemotherapy for malignant pleural dissemination and effusion
Ann Thorac Surg
Pleural space perfusion with cisplatin in the multimodality treatment of malignant mesothelioma: A feasibility and pharmacokinetic study
J Thorac Cardiovasc Surg
Operation and photodynamic therapy for pleural mesothelioma: 6-year follow-up
Ann Thorac Surg
Demographic patterns for mesothelioma in the United States
J Natl Cancer Inst
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
Extrapleural pneumonectomy in the multimodality therapy of malignant pleural mesothelioma. Results in 120 consecutive patients
Ann Surg
Methods to improve the diagnostic accuracy of malignant mesothelioma
Respir Med
Malignant pleural mesothelioma
Thoracoscopy in pleural malignant mesothelioma: A prospective study of 188 consecutive patients. Part 1: Diagnosis
Cancer
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Address reprint requests to David J. Sugarbaker, MD, Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston MA 02115.