The results of a study published recently in The Journal of Thoracic and Cardiovascular Surgery supports the use of extrapleural pneumonectomy-based multimodal therapy in carefully selected patients with malignant pleural mesothelioma. The Journal is published by The American Association for Thoracic Surgery.

According to the research summary, the objective of the study was to evaluate the perioperative and long-term outcomes associated with extrapleural pneumonectomy for patients with malignant pleural mesothelioma. Pleural mesothelioma affects the lining of the chest cavity and lungs. Other forms of mesothelioma include pericardial, which affects the lining of the heart and is extremely rare; and peritoneal, which affects the lining of the abdomen. Mesothelioma is atributed almost exclusively to asbestos exposure.

According to the Multimedia Manual of Cardiothoracic Surgery, extrapleural pneumonectomy was introduced in the 1940s for the treatment of extensive infections of the lung and pleural space. Over the past 20 years, the extrapleural pneumonectomy technique has been modified and applied to the treatment of locally advanced malignant pleural mesothelioma, achieving substantial reductions in mortality. The surgery involves the removal of the lung with visceral and parietal pleurae, pericardium and diaphragm.

Researchers selected 70 patients between October 1994 and April 2008 to undergo the procedure. Prognostic factors included age, gender, side of disease, asbestos exposure, histology, positron emission tomography, date of surgery, neoadjuvant chemotherapy, completeness of cytoreduction, lymph node involvement, peioperative morbidity, adjuvant radiotherapy and pemetrexed-based chemotherapy.

The mean age of patients was 55 years. The median survival was 20 months, with a 3-year survival of 30 percent. Analyses showed improved survival for patients with asbestos exposure, negative lymph node involvement, and receipt of adjuvant radiation or postoperative pemetrexed-based chemotherapy.

The study was conducted by physicians from the University of Sydney, Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital; The Baird Institute for Applied Heart and Lung Surgical; Department of Medical Oncology, Sydney Cancer Center, Royal Prince Alfred Hospital; and Department of Radiation Oncology, Sydney Cancer Center, Royal Prince Alfred Hospital; all in Sydney, Australia.

Among the most interesting discussions at the recent International Symposium on Malignant Mesothelioma, held in Washington, D.C., June 25-27, was a panel discussion about the challenges of finding treatment once a patient is diagnosed with mesothelioma. The panel featured physicians from three of the leading programs in treating peritoneal mesothelioma, Dr. Paul Sugarbaker, Dr. H. Richard Alexander, and Dr. John Chabot.

Peritoneal mesothelioma affects the lining of the abdomen, and makes up about 10-15 percent of all mesothelioma diagnoses. The more common form of mesothelioma is pleural, which affects the lining of the chest and lungs. All mesothelioma is linked to asbestos exposure.

The current “best practice” for the treatment of mesothelioma is a multi-modality approach, which is a combination of surgery and chemotherapy, along with immunotherapy.

“It’s a sequence of treatments that make sense,” Dr. Chabot explained.

However, Dr. Sugarbaker pointed out, only a small fraction of mesothelioma patients receive multimodality treatment.

“So many more things could be done to manage the treatment of this rare disorder,” Dr. Sugarbaker said. “We should have accumulated many thousands of data points on people with peritoneal mesothelioma. Unfortunately, a majority of patients in the U.S. do not get to a treatment center.”

There are still only a handful of treatment centers that specialize in mesothelioma, and even then there are distinctions in the treatment of peritoneal or pleural mesothelioma that narrows the field even further. Also, there are not a large number of physicians currently treating mesothelioma, and no established surgical training programs specifically for this field to develop more doctors experienced in mesothelioma treatment.

Awareness also is still an issue. Many patients are diagnosed too late for effective treatment.

Even if awareness is high and a patient is diagnosed early enough to be a viable candidate for successful mesothelioma treatment, the logistics of receiving treatment can be difficult. Most of the centers for mesothelioma treatment are located on the East Coast. There is one on the West Coast, but almost no options in the Midwest or other areas of the country. Treatment is usually extended over many months, making it necessary for patients to relocate to be near a treatment center if they are not lucky enough to live nearby.

“People often move and rent temporary housing. People live in trailers,” Dr. Chabot said. “More advocacy is needed to provide patient and family support for treatment. The travel issues for people who need treatment are huge.”

The Mesothelioma Applied Research Foundation, which sponsors the annual Meso Symposium, is laying the groundwork to facilitate discussions and establish a collaborative strategy, simply by bringing together the experts in this field. There is an emphasis now on forming a consortium to establish a new standard of care, and to try to combine the knowledge of the existing research and treatment centers, and to expand access to that research and treatment.

But, the experts acknowledge, there is still much to do.