Updated: 9 July 2005
Referral Information for the New Patient Visit
Patients not previously seen at the BCCA may be referred to a cancer center for consultation and management by contacting the Admitting Department of the geographically appropriate center. The availability of relevant operative, pathology and imaging laboratory reports will be requested so that these can be obtained prior to the patient being seen, together with the relevant slides and radiographs for review. The courtesy of a brief referring letter or phone call is appreciated.
Best Practice Guidelines
Treatment of mesothelioma has proved disappointing, regardless of the modality used. Retrospective evaluation of treatment is difficult because of differences in patient groups at presentation and small numbers of patients available for clinical trials. All patients with pain require supportive care with aggressive use of analgesics; narcotic analgesics palliate dyspnea as well as pain. Given the restriction in lung function seen in individuals with pleural mesothelioma, strategies to maintain optimum lung function are recommended. Smoking cessation is to be encouraged. Pneumococcal vaccine, and the influenza vaccine when available for the season, should be administered.
Surgery
Patients with stage I mesothelioma are occasionally considered for extrapleural pneumonectomy. Although some patients have been reported to achieve long-term survival with aggressive therapy, such cases are highly selected and it is unclear whether overall survival has been significantly altered by the treatment modalities applied. Mortality from extrapleural pneumonectomy ranges from 6% to 30%. Because mesothelioma patients suitable for extrapleural pneumonectomy are rare, such cases should be referred to a thoracic surgeon with experience in performing such operations.
Standard surgical therapy for stages I-IV mesothelioma includes drainage of effusions, chest tube pleurodesis, or thoracoscopic pleurodesis. Effusion control may be difficult because of the restrictive nature of the tumour. Selected patients may be considered for palliative surgical resection and decortication. Such procedures may provide temporary relief from effusions but there is no established surgical role for palliation of pain associated with chest wall invasion. Operative mortality from pleurectomy/decortication is about 2%.
Radiotherapy
The role of radical radiotherapy is limited by the volume being treated (the entire hemithorax), the surrounding structures (heart, liver), and the requirement for delivery of a high dose. Palliative treatment of more localised symptomatic areas such as painful areas of the chest wall or involvement of the mediastinum may be feasible.
Chemotherapy
Recent clinical trials support considering treatment of mesothelioma with chemotherapy. However, as the rate of disease progression is highly variable, it is reasonable for patients who have few or no symptoms to be managed expectantly. A trial of systemic chemotherapy may be offered to fit patients with symptoms requiring palliation. The probability of benefit is greater in those with epithelioid tumours.
Pemetrexed in combination with a platinum analog is a standard consideration due to the survival benefit seen in a large randomized trial that compared pemetrexed plus cisplatin to cisplatin alone. Alternatives include gemcitabine in combination with a platinum analog, monotherapy with vinorelbine, or an investigational protocol.
Intracavitary therapy with chemotherapeutic agents (cisplatin, mitomycin or cytarabine), cytokines (interferon), radionuclides, and porphyrin/laser have been reported to induce transient regression of mesothelioma but none of these approaches have demonstrated superiority to supportive care only.
References:
- Byrne MJ, Davidson JA, Musk AW, et al. Cisplatin and gemcitabine treatment for malignant mesothelioma: a phase II study. J Clin Oncol 1999; 17: 25-30.
- Steele JP, Shamash J, Evans MT, Gower NH, Tischkowitz MD, Rudd RM. Phase II study of vinorelbine in patients with malignant pleural mesothelioma. J Clin Oncol 2000; 18: 3912-3917.
- Vogelzang NJ, Rusthoven JJ, Symanowski J, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol 2003; 21: 2636-2644.
Follow-up
Mesothelioma patients are generally treated palliatively and follow-up depends on symptomatology and treatment modality used. The BCCA doctor in charge should explicitly clarify the physician in charge of palliative patient follow-up. For patients followed by their referring physicians, the BCCA physicians will act as consultants if requested.