Mesothelioma of the pleura, peritoneum: treatment, symptoms, prognosis
Mesothelioma is a neoplasm of the cells of serous membranes, covering the body cavity and many of the internal organs. The disease is quite rare, usually affects the pleura (75% of cases), rarely the peritoneum (20%) and rarely the pericardium. Among patients are men over the age of 50, though may develop tumors even in young children.
Mesothelioma can be benign, but in most cases the tumor is malignant, aggressive and is characterized by poor prognosis. Although the disease is considered rare, recent years have seen a steady increase in the number of patients with mesothelioma, and by 2020 it is expected a significant increase in the number of cases of the tumor. Among European countries, this disease leads UK, where a decade ago the mortality rate from mesothelioma was higher than that from cervical cancer and melanoma.
The effect of some carcinogens, in particular asbestos, delayed and appears after 20-50 years, so the projected significant increase in the incidence of tumors in those countries where at the end of the last century there was an active mining of asbestos. Thus, the former Soviet Union in 1984 he won first place in the production of asbestos, so it is natural to expect an increase in the incidence of mesothelioma to 2020-25 years in Russia.
Mesothelioma at the initial stages may be asymptomatic, but her steady progression and spread on serous cover lead to serious disorders of internal organs. To fight this tumor is extremely problematic, and even when using the entire spectrum of antitumor activities, the forecast continues to be disappointing: most patients die within the first year after diagnosis.
The causes of mesothelioma
Regardless of the location of the tumor, leading factor that leads to mesothelioma, is the asbestos. This mineral is able to penetrate into the serous membrane, accumulate there and in a few decades to show their carcinogenic effect.
Among other reasons noted:
- Some chemicals (Nickel, liquid paraffin, copper, etc.) acting as a professional harmful factors.
- Genetic predisposition (family cases of mesothelioma).
- Radiation therapy in connection with other malignant tumors.
Asbestos is an extremely dangerous mineral, small fibres which can get into the respiratory tract and lymph flow to move in serous integument, usually pleura. Contact with them is when working in the mines, where he mined, the production of materials in the glass industry. Also risks and people living near the sites of production. Usually a meeting with the carcinogen occurs at a young age, and the disease develops much later, so some patients may deny the fact of working in such hazardous conditions.
Among patients in 8 times more men than women. It is likely that this is due to professional activities, because men often work with harmful and heavy production. Contact with carcinogens at a young age, they encounter mesothelioma is closer to 50 years. Younger patients and even children are a minority.
Types and symptoms of mesothelioma
Mesothelioma is a primary tumor that grows from cells of the serosal lining of organs and cavities. At the initial stage it appears in the form of small lesions or nodules, which gradually increase or spread across the surface of the mesothelium. Depending on the growth of isolated nodal form and diffuse mesothelioma, where the tumor envelops the affected body like a shell.
Growing between the sheets of pleura, pericardium or peritoneum, the tumor causes inflammation and the production of large amounts of fluid (exudate tumor) that occurs in most patients and causes severe disease. The effusion into the serous cavity leading to compression of organs and the violation of their functions, so the result is often respiratory failure, heart failure, intestinal obstruction.
Histological tumor features allow you to select several options:
Malignant mesothelioma spreads rapidly over the surface of the serous membrane, grows into surrounding organs and tissue, damaging them, and metastasizes mainly by lymphogenous. The growth of the tumor leads to a rapid depletion and dysfunction of vital organs.
Mesothelioma of the pleura (lungs)
Pleural mesothelioma is the most common type of the disease occurring in older men, once exposed to the asbestos. Starting the layer growth, tumor a few years does not give any characteristic symptoms. Increasing its volume of patients start to worry:
- Shortness of breath;
- Chest pain;
- The decrease in body mass.
In some cases, the disease is manifested only by fever or accumulation of fluid in the pleural cavity, which is more typical for diffuse forms of tumor growth.
The most common symptoms of mesothelioma is shortness of breath, and then cough. These symptoms many patients tend to ignore, explaining their age-related changes, chronic diseases of broncho-pulmonary system (especially in smokers), heart problems. The accession of pain, sometimes quite intense, unexplained fever, noticeable weight loss is alarming and cause to exclude the fact that the growth of malignant tumors.
Up to 80% of patients with pleural mesothelioma suffer from exudative pleural effusion when the chest cavity constantly produce large amount of fluid is sero-fibrinous, or bloody nature. This picture not only gives severe pain, but also exacerbates the shortness of breath due to compression of the lung tissue, and with a significant amount of fluid possible shift of the mediastinum, arrhythmia and heart failure.
The swelling rapidly spreads through both pleural layers can penetrate into the pericardium, diaphragm, abdominal cavity, grow into ribs and muscles of the chest wall. Sprouting in the region of the larynx, mesothelioma provokes violations of voice and the ability to play sounds, dysphagia (difficulty swallowing). Metastasis of mesothelioma found in regional lymph nodes, opposite lung, the heart shirt.
Mesothelioma of the peritoneum (abdominal cavity)
The peritoneal mesothelioma is found in significantly less common than pleural but they have a common cause – contact with asbestos. Symptoms of tumor in the early stages subtle and not too worried about the patient because the abdominal discomfort and even pain felt by many, especially the elderly. Further increase in symptoms in form of vomiting, diarrhea, nausea, severe weight loss and abdominal distension due to fluid accumulation makes you think about the presence of a malignant tumor.
Mesothelioma of the pericardium (heart)
Mesothelioma of the pericardium is considered the most rare localization of the tumor. Spreading on the surface of the serous membrane of the heart, tumors produce symptoms when reaching quite large sizes. Signs are reduced to chest pain and disorders of the cardiovascular system – arrhythmia, heart failure, a tendency to hypotension. A significant volume of the tumor can greatly compress the heart, causing acute heart failure and signs of pericardial tamponade.
Diagnosis of mesothelioma
To diagnose mesothelioma after inspection and conversations with patients:
- Chest x-ray, enabling to detect a lesion of the pleura, lung, pericardium, accumulation of fluid in these cavities;
- CT and MRI of the thorax, the heart;
- Pleural ultrasound, abdominal cavity;
The primary means of obtaining tumor cells for cytological examination is to puncture the pleural, abdominal, pericardial. The abundance of fluid in combination with the above mentioned symptoms usually speaks in favor neoplasia, and extracted the contents of the detected malignant cells.
The most accurate result possible with the biopsy of the fragments of the tumors during laparoscopy (in the case of intra-abdominal localization of the tumor), thoracoscopy in mesothelioma of the pericardium or pleura. After histological examination of sections of the tumor established the form of mesothelioma, which determines the tactics and the prognosis of the disease.
Mesothelioma treatment is a very difficult task. Due to the high malignancy of tumor, even the use of all possible methods of anticancer treatment can only slightly extend the patient’s life. The average life expectancy of patients with mesothelioma, even during the active treatment less than two years, so the event is mainly aimed at relief of symptoms and the suspension of tumor growth. Many of the intervention on the chest cavity is very traumatic, and since the tumor is often detected in people of middle and old age, radical surgery can be significant contraindications.
For the treatment of mesothelioma is usually used:
- Surgical method;
- Photodynamic therapy;
Treatment of pleural mesothelioma
Surgical intervention is the main, but it can be carried out not for each patient, and the volume of it is often restricted to palliative purposes. Radical surgery involve the removal of the lung and pleura, possible excision of neoplastic tissue with preservation of the lung and palliative care lies in the imposition shunts or pleurodesis that prevent the formation of excess exudate.
The goal of palliative surgery is to reduce pain and relieve the patient from accumulation of fluid in the pleural cavity with compression of the lung tissue.
Severe manifestation of a tumor is the accumulation of pleural effusion in the thoracic cavity. Liquid is formed quite a lot, it limits the mobility of the lung and leads to respiratory problems and cardiac arrest.
As a palliative method can be carried out pleurotes spray talc with diagnostic thoracoscopy. The talc causes the formation of adhesions in the affected pleural cavity, the pleural layers are fused together, and the possibility of permanent drainage is eliminated. The efficiency of the operation reaches 80-100%, but if there is a total tumor lesion of the serous membranes and atelectasis, the procedure will not bring the desired result. In this case, preferably, the overlay, pleuro-peritoneal shunt to drain excess fluid into the abdominal cavity.
Another option of palliative treatment is pleurectomy – removal of the pleura to prevent production fluid, and the inability of this method to the patient and spend thoracocentesis – puncture and evacuation of the contents of the chest cavity. Pleurectomy involves the removal of the entire parietal and part – visceral pleura, and, if necessary, portions of the pericardium and diaphragm. Surgery should be complemented with chemotherapy and shows good results even with significant neoplastic lesions. Pleurectomy allows not only to eliminate some of the severe manifestations of mesothelioma, but also to extend the life of patients from 4 to 14 months.
The most radical and the most traumatic method of surgical treatment of pleural mesothelioma is extrapleural pneumonectomy. This operation can be carried out not more than 10% of patients due to the high operational risk and initially severe condition of the patient. Extrapleural pneumonectomy involves the removal of the entire lung with the visceral leaflet of the pleura, parietal pleura, pericardium and half the diaphragm. This extensive procedure can be performed only to patients with early stages tumors and in satisfactory General condition. In the presence of pathology of the cardiovascular system and on the other lung, the elderly, the risks exceed possible benefits, so patient selection is carried out very carefully.
Mortality after radical surgical treatment is 10%, and complications such as atrial fibrillation, coagulation disorders occur in the majority of patients. Despite this, such interventions still being held, and to raise their efficiency is possible by combination with chemotherapy and irradiation.
Radiation therapy directed at elimination of pain and relief of other symptoms of the tumor, but the duration of life it did not significantly extend. Radiation requires high doses of radiation and can be performed remotely, and in the form of local injection of radioactive particles. High risk of radiation complications associated with damage to the parenchyma of the lung, and low sensitivity of the mesothelioma to radiation do not allow to use the method as the core, but when combined with surgery and chemotherapy radiation gives a good result. If the patient removed the whole lung, it is possible to use higher doses of radiation with less risk of dangerous complications. When surgery is impossible, radiation therapy becomes palliative in nature and can reduce pain, shortness of breath, difficulty swallowing.
Chemotherapy is the appointment of anticancer drugs that can be inserted into a vein and directly into the pleural cavity. Mesothelioma is not sensitive to chemotherapy, but cisplatin in combination with other agents may improve the patient’s condition. Cisplatin as the most effective drug for mesothelioma, is included in all standard regimens.
Combined treatment of mesothelioma includes surgical intervention (pleuropneumonectomy), and then after 4-6 weeks you receive chemotherapy, where the binding component is cisplatin. After surgery and chemotherapy irradiate the affected part of the body. It is worth remembering that each method is associated with serious side effects that can be amplified when combined. So, nausea, vomiting, fatigue can be exacerbated by the appointment of chemotherapy and concurrent radiation. This fact is always taken into account, and to facilitate the patient is symptomatic.
The efficiency and other methods to combat the tumor. Possible use of interferon and interleukin in addition to chemotherapy, and the use of targeted therapies (Avastin, iressa, thalidomide) already shows good effect. Mesothelioma contains a large number of vessels, and hence the level of expression of vascular growth factor is quite high. A deliberate effect of targeted therapy on the individual links of the pathogenesis of the tumor allows to reduce the intensity of its growth and to improve results of combined treatment.
Mesothelioma of the pericardium and peritoneum
In the treatment of peritoneal mesothelioma and pericardial approaches are not fundamentally different from those in the case of lesions of the pleura. With the accumulation of excess fluid in these cavities possible puncture. The extraction of exudate from the cavity of the heart shirts allows you to improve the function of the heart, which is compressed by the exudate.
If the tumor is small and the condition of patients satisfactory, you can try to remove the tumor along with affected tissue. Mesothelioma of the peritoneum is usually accompanied by the common character of tumor growth, therefore, to excise the tumor along with a portion of the abdominal wall is possible only in the initial stages of the disease, but the effect of the interference is not always good. Mesothelioma of the pericardium is to be removed along with the diseased heart, for obvious reasons.
The tumor spreads rapidly over the surface of serous membranes, therefore, even in case of radical surgery, there is a high risk of maintaining the tumor cells in other parts of the peritoneum or pericardium, causing recurrence and disease progression is inevitable. Chemotherapy and radiation possible, as in the case of pleural mesothelioma, in combination therapy.
The prognosis of mesothelioma of any localization is poor. Tumor cells spread quickly on serous cover, so the recurrence rate is high. Severe General condition of patients, older age, a significant amount of spread of the tumor do not allow for radical surgery many patients, therefore surgical treatment is often only palliative.
Without treatment the mesothelioma life expectancy does not exceed 6-8 months. Combination therapy allows to prolong it to a maximum of two years.
In connection with this circumstance when assessing the effectiveness of the treatment is used not the 5-year survival, and the so-called median, which is equal to the average 13-15 months. Up to 5 years after treatment can live units. Research to find the most efficient and effective methods of surgical treatment and its combination with other methods continue.