Hello my name is dr. Alex Farber and I’m a thoracic surgeon at the Swedish Cancer Institute and Medical Center in Seattle Washington. I would like to talk to you today about tumors involving the pleura and in specific malignant pleural mesothelioma in this podcast. We will talk about what the pleura is and possible treatment options for cancer involving the pleura with respect to anatomy of the pleura each lobe of the lung is covered by a double layer sac. That we term pleura this covers the lung it lines the chest wall diaphragm and mediastinum.
We called a layer that covers the lung the visceral pleura we term the layer that covers the chest wall the parietal pleura pleura also lines the diaphragm. As well as the pericardium the SAC around the heart the space between the two pleural layers is termed the pleural space. There are approximately two to three thousand new cases of primary cancers of the pleura or malignant pleural mesothelioma that are diagnosed each year in the United States.
We know that remote exposure to asbestos is a risk factor for developing mesothelioma tumors of the pleura can also be in our most often secondary. To metastases from cancer involving distant parts of the body such as colon prostate and ovary while primary pleural malignancies and this is defined as tumors. That arise from the pleura itself are fairly uncommon therefore physicians tend to have a difficult time making the initial diagnosis of mesothelioma. We continue to learn more about malignant pleural mesothelioma with respect to the diagnosis management and possible treatment options.
Chemotherapy Radiation And Surgery
We now know that for a subgroup of patient multi-modality therapy or the combined use of chemotherapy radiation and surgery is associated with better outcomes. Than the use of any single one of those treatment options alone. Therefore survival of our patients with mesothelioma is beginning to improve up to 80% of cases of mesothelioma are associated with asbestos exposure. The remaining cases can be related to family contact as well as non asbestos type causes people most often are diagnosed.
With mesothelioma and their 50s to 70s and males are affected more often than females. It can be difficult to differentiate a malignant pleural mesothelioma from a different type of cancer. That we call metastatic adeno carcinoma these are two completely different types of cancer. With vastly different treatment options as I mentioned before pleural tumors are more frequently metastatic cancers. Than mesothelioma and so we utilize many different tests to accurately make that distinction it is crucial that we have enough tissue sample or a large enough. Biopsy specimen to adequately characterize not only the tumor as a mesothelioma.
But also to distinguish which subtype of mesothelioma we have in specific epithelioid sarcoma toyed or mixed epithelioid. Mesothelioma is the more favorable subtype of mesothelioma and carries a greater chance of survival after surgical and multi modality therapy. Sarcoma toward mesothelioma is composed of spindle-shaped cells and these tumors tend to have a less. Favorable outcome part of the difficulty in making a diagnosis of mesothelioma are there subtle symptoms that our patient exhibits. Dyspnea or difficulty with breathing is the most common symptom and that is usually due to the presence of a pleural effusion characterized.
Visceral Pleura And The Parietal Pleura
In blue this accumulates in the spaces between the visceral pleura and the parietal pleura in between the lung and the chest wall chest pain. Can also be common other symptoms include cough loss of appetite weight loss night sweats and even hemoptysis or spitting up. Blood on physical exam there may be decreased breath sounds on the affected side there can also be a mass. In the chest wall and this could be painful there are a number of Radiologic tests that we order. While trying to establish the diagnosis the stage which tells us how advanced the cancer may be in determine.
If surgery is feasible and in the best interest of the patient CT scans of the chest are usually one of the first tests. That we order it is readily available and it provides some very useful data PET scans help determine. If there’s any suggestion of disease in the other lung in the abdomen or in other areas of the body at times. MRI can suggest invasion into the chest wall mediastinum or across the diaphragm into the abdomen this usually indicates that surgery would not be an option. That would benefit the patient all the information we gather including CT MRI PET. As well as histology from the tissue biopsy is used to gain a better idea of the anatomy of one’s mesothelioma and whether surgery.
Mesothelioma Is Typically A Thoracentesis
Will be of potential benefit for the patient the first invasive test used in an attempt to make a diagnosis of mesothelioma is typically a thoracentesis. Or when fluid is removed from the pleural space a thoracentesis is the use of a small catheter to drain pleural fluid. That is sent for analysis to a pathologist to see if cancer cells are indeed present it is not uncommon. That the pleural fluid is analyzed and does not indicate a diagnosis of mesothelioma or even cancer at all even if cancer is present. In that space oftentimes the next step is the use of a CT scan to guide a pleural biopsy this yields a diagnosis of mesothelioma approximately thirty to fifty percent of the time better. But still not great with respect to making a definitive diagnosis of mesothelioma lastly an operation. Can be performed usually through a single small incision in the chest wall a video scope is introduced into the pleural space and multiple biopsies are taken of the pleural surfaces.
Thoracic Surgeon With Experience
This is often a diagnostic intervention that results in a definitive diagnosis of malignant pleural mesothelioma. At this point the patient typically is referred to a thoracic surgeon with experience and treating patients with mesothelioma. As is true with any cancer we treat we stage every patient with mesothelioma in other words we determine. How advanced we believe the cancer to be when we attempt to determine. The best treatment option possible we utilize all the data available to us including the CT PET CT MRI. Tissue biopsy and eventually add a procedure in the operating room called a cervical mediastinum skippy.
This is a procedure where a small incision is made at the base of the neck and mediastinal lymph nodes are biopsied we now know that. If the mediastinal nodes are negative for cancer meaning no cancer is present that. These patients live longer than if the nodes are involved with cancer. If we suspect the possibility of mesothelioma existing in the abdomen we may perform a laparoscopy to assess this involves going to the operating room. Where a small incision and cameras are used to obtain tissue to prove. To prove the presence or not of mesothelioma in the abdomen there are two operations. That thoracic surgeons may consider performing for patients with mesothelioma. These are named pleure ectomy in decortication or extra pleural pneumonectomy cleric t’me and decortication is a surgical procedure.
That involves removing both the viscera and parietal pleura this leaves the lung in place this can be a potential option for patients. With very minimal or very advanced disease an extra pleural pneumonectomy is the complete removal of the lung. With its visceral pleura the parietal pleura the diaphragm and the SAC around the heart termed. The pericardium we then reconstruct both the pericardium as well as the diaphragm using prosthetic material. We believe extra pleural pneumonectomy to be the better choice for people. Who are strong are younger or who have more bulky disease there is no gold standard therapy for mesothelioma.
Describing Our Treatment Philosophy
Your treatment plan depends on the anatomy of your tumor and your overall status sometimes chemotherapy is done. Before surgery our thoracic group from Swedish has a recent publication describing our treatment philosophy and results and patients. With mesothelioma treated with chemotherapy first followed by surgery and then radiation patients with mesothelioma are better managed. In centers where there is experience and treating this type of cancer. As well as with the complex surgical procedures required for removal of the entire tumor only by centralizing. The care for the small number of new patients with mesothelioma seen every year to a limited number of medical centers can. We continue to study learn and improve outcomes for our patients fighting this cancer in the past mesothelioma was considered.
To be a disease that could not be treated in which only pain management should be offered. We have come a long way from those days we now know. There are interventions that can help certain patients live longer and more comfortably. The surgeries that we offer to patients have improved our ability to make accurate diagnosis before we head to the operating room. We continue to experiment do research and study our results critically. Thank you for reading to the plugged into your health cancer podcast program mesothelioma and malignant pleural issues in thoracic surgeries. For more information please contact your thoracic surgeon