Mesothelioma Treatments

Mesothelioma treatments are chosen based on the stage, and the location of the cancer. There are several options available:

Surgery for Mesothelioma

Mesothelioma surgery may either be potentially curative, or palliative. Potentially curative surgery is applicable to resectable mesothelioma, where it is possible to rid the body of all cancerous tissue by removing the infected parts. 

Palliative surgery is done to alleviate pain and other symptoms, when complete removal is no longer viable. 

Types of Surgery for Pleural Mesothelioma

Extrapleural Pneumonectomy (EPP)

This extensive surgery, performed only at major medical centers by experienced surgeons, involves removing the following:

• Affected lung, 
• Pleural lining, 
• Diaphragm, 
• Potentially the heart sac (pericardium), 
• Nearby lymph nodes

Synthetic materials may also be used to reconstruct the diaphragm and pericardium. 

While offering the best chance for complete cancer removal in patients with resectable epithelioid mesothelioma without lymph node involvement, it requires excellent overall health and lung function. About one-third of patients experience major complications.

Pleurectomy/Decortication (P/D)

This less extensive operation involves removing the pleura lining from the chest wall, lung, mediastinum, and diaphragm on the affected side, while preserving the lung and diaphragm muscle. 

An extended version (radical P/D) may include removal of the diaphragm and/or pericardium. This procedure can be used either as a curative treatment for early-stage cancers or as a palliative measure to improve breathing, control fluid buildup, and reduce pain.

Debulking (Partial Pleurectomy)

This is the least extensive surgical option, aimed at removing as much of the mesothelioma as possible, though less tissue is removed compared to a P/D procedure. It serves primarily as a palliative treatment to reduce tumor burden and improve symptoms.

Surgery for Peritoneal Mesothelioma 

Debulking

Debulking is a form of palliative surgery that aims to remove as much mesothelioma as possible, even when the cancer is no longer fully resectable. This increases the efficacy of chemotherapy. 

Omentectomy

This surgery removes the apron-like tissue layer that drapes over the organs called the omentum. Since cancer is likely to spread to this area, it may be fully removed as part of surgery for peritoneal mesothelioma. 

Surgery for Pericardial Mesothelioma

The pericardium is a sac around the heart, and it may be completely removed in a pericardectomy to ease pressure build up. A hole called a pericardial winnow may also be placed in this area to allow for the administration of chemotherapy drugs. 

Surgery for Mesothelioma of the tunica vaginalis 

This type of mesothelioma is rarely cured by surgery, but is often discovered in patients suspected of hernias. Tissue samples from an attempted hernia removal may be analyzed in the laboratory to confirm the presence of mesothelioma. 

Palliative Procedures for Mesothelioma 

Palliative procedures or palliative care are procedures done to ease the pain and reduce symptoms for cancer. For mesothelioma, they may be any of the following:

• Fluid Removal: fluid that builds up and causes swelling in the affected areas is drained
• Pleurodesis: a cut is made in the skin of the chest wall and a tube is attached to allow for easier fluid drainage
• Shunt Placement: a shunt, which allows fluid to move from one area of the body to another, is placed to divert fluid buildup and prevent swelling
• Catheter Placement: a catheter, which is a thin flexible tube, is placed in the chest or abdomen,through a small cut in the skin, with the other end draining outside the body  

Radiation Therapy for Mesothelioma

Radiation therapy uses high-energy X-rays to saturate and kill cancer cells. Mesothelioma is not as responsive to radiation as other cancers, but there are cases where it can still be employed:

External Beam radiation Therapy (EBRT) 

This type of radiation comes from a machine outside the body, which is directed to the affected area to kill cancer cells. Newer modes like Intensity-Modulated radiation Therapy (IMRT) allows for more accurate targeting with reduced damage to surrounding areas. 

Brachytherapy 

This type of radiation therapy involves embedding radiation sources in the tumors or near the cancer. This is usually in the form of radioactive pellets. This method is still in the clinical trial phase and is not widely used for mesothelioma treatment. 

Chemotherapy for Mesothelioma

Chemotherapy uses high-potency anti-cancer drugs to combat the growth of cancer cells. However, they may also affect the growth of any fast-growing and fast dividing cells like hair, nail, and skin cells. 

Chemo is given in cycles, with rest periods in between, to prevent the potent drugs from severely depleting and compromising the patient’s health. For mesothelioma, it is usually given as a neoadjuvant therapy, or prior to surgery to increase the likelihood of success. Chemo can be administered according to the following methods:

Systemic Chemotherapy 

This method involves directly injecting chemotherapy drugs into the bloodstream through a vein. The drugs course through the bloodstream and kill off cancer cells wherever they may be located. 

Intrapleural or Intraperitoneal Chemo 

This is a more direct administration of chemotherapy drugs, either in the pleura or the peritoneum, and is usually done through a catheter tube. While still absorbed in the bloodstream, the higher concentrations will be at the sites affected with mesothelioma, which increases potency. 

Mesothelioma Chemo Drugs

The following drugs are commonly used for mesothelioma chemo treatments:

• Pemetrexed 
• Cisplatin
• Carboplatin
• Gemcitabine 
• Vinorelbine

These drugs are usually combined, depending on the case. But they may also be used solo if the patient is already in poor health and cannot withstand the potency. 

Side Effects of Chemotherapy

Since chemo drugs attack fast-growing and fast-dividing cells of all kinds, the following  side effects may be felt during the treatment process and immediately after:

• Balding
• Mouth sores
• Appetite loss
• Nausea 
• Diarrhea
• Blood problems

Immunotherapy for Mesothelioma

The immune system can fight off both cancer and anticancer drugs. Sometimes, cancer can hide behind immune checkpoints, making treatment less effective. These checkpoints can be turned off through the administration of immune checkpoint inhibitors, which help the immune system react more vigorously and may be used to treat mesothelioma:

PD-1 Inhibitors

• Pembrolizumab
• Nivolumab

CTLA-4 Inhibitors

• Ipilimumab 

Side Effects of Immune Checkpoint Inhibitors

These drugs often carry side effects that are also common with chemo drugs such as:

• Fatigue
• Cough
• Nausea
• Itching
• Skin rash
• Decreased appetite
• Constipation
• Joint pain
• Diarrhea

But the biggest danger in these drugs is called an ‘autoimmune reaction’, which is when the immune system goes out of control and attacks other organs like the heart, liver, and lungs. Should this occur, doctors may need to administer immunosuppressants like corticosteroids, and stop the treatment altogether. Consistent monitoring is essential, so that whenever any symptoms arise, they can immediately be addressed. 

Targeted Drug Therapy for Mesothelioma 

There is ongoing research into specific protein and gene changes in mesothelioma that can be targeted with special drugs when regular chemo drugs no longer work. 

For Mesothelioma, drugs that target blood vessel formation are now being studied as potential treatment alternatives. A protein called vascular endothelial growth factor (VEGF) has been seen to help tumors grow and form new blood vessels. Using a drug called Bevacizumab, VEGF can be deactivated. This has been found to help patients suffering from pleural mesothelioma, when used together with chemo drugs like cisplatin. 

However, these are still in the testing phase, and the following side effects are also currently observed with this treatment:

• High blood pressure
• Extreme tiredness (fatigue)
• Bleeding
• Low white blood cell counts (with increased risk of infections)
• Headaches
• Mouth sores
• Loss of appetite
• Diarrhea

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