Frequently Asked Questions

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Checklist: Tests and Information Checklist: Communicating with Your Doctor

Before your next appointment, get the answers to frequent questions.  Do you need more help? Call our office at (310) 478-4678 and speak with Jessica Like.

What exactly is mesothelioma? What are the symptoms?
How is it diagnosed? How is mesothelioma staged?
How is mesothelioma treated?  

What exactly is mesothelioma?

Malignant mesothelioma (MM) is a rare form of cancer that usually develops in the lining of the chest or abdomen and affects approximately 3,000 people every year. Specifically, mesothelioma affects protective sacs known as mesothelium that cover most internal organs.  Mesothelium sacs are actually a flat layer of cells which produce lubricating fluid.  However, like any form of cancer, MM begins when a cell or group of cells undergoes a change that causes it to grow uncontrollably.  The cancer can then metastasize or spread throughout the body’s blood vessels or lymph system to other areas inside the body.

Pleural: Mesothelioma found in the pleura (the thin layer of tissue that lines the chest cavity and covers the lungs) is known as pleural mesothelioma and accounts for approximately 90% of all mesothelioma cases.

Peritoneal: Mesothelioma located in the thin layer of tissue that lines the abdomen and covers most of the organs in the abdomen is known as peritoneal mesothelioma. 

Sub Types: There are two common cell types for MM known as epithelial and sarcomatoid type. Epithelial malignant mesothelioma is the most common and accounts for 50-70% of all MM. Epithelial mesothelioma is so called because it affects the epithelial or tissue membranes that line internal organs. Approximately 60% of all epithelial cases occur in the pleural tissues of the lungs, usually the right lung. Patients who develop epithelial type mesothelioma often have a better prognosis and an increased chance of survival time because it is the least aggressive type.

Sarcomatoid mesothelioma is the second most common type which accounts for 7-20% of mesothelioma cases. This type of mesothelioma affects the connective tissues.

Patients can also develop a combination of epithelial and sarcomatoid known as biphasic mesothelioma. This occurs approximately 20-30% of the time. Patients should know which type of mesothelioma they have so that they may pursue the most appropriate treatment option first. For epithelial or biphasic patients who are predominantly epithelial, surgery may be the best initial treatment.

How common is mesothelioma?

Mesothelioma is relatively rare. Somewhere between 2,000 and 4,000 new cases are reported each year. It is more common among men than women in North America. However, this does not necessarily mean that men have a higher likelihood of developing mesothelioma. Traditionally, more men than women have worked with and been exposed to asbestos either through their occupation or through their household work. Thus, because a disproportionately larger number of men than women have been exposed to asbestos, it is understandable that more men than women develop malignant mesothelioma (MM).

Mesothelioma has an unusually long latency period, meaning that after asbestos exposure, symptoms usually do not appear for 20 – 50 years.  MM has also been documented in a very wide age range. Once symptoms do occur, the cancer can progress quickly. Patients diagnosed with mesothelioma should seek immediate treatment from a specialist.

What causes mesothelioma?

Known asbestos exposure is reported in 70-80% of mesothelioma cases. Asbestos increases the risk of lung cancer, asbestosis, and other diseases, but most notably mesothelioma.

When asbestos is inhaled, it can cause pleural mesothelioma which occurs inside the chest and grows throughout the pleural space around the lungs. When asbestos is ingested, it can cause peritoneal mesothelioma which affects the abdomen and nearby organs.

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What are the symptoms of mesothelioma?

MM has a long latency period. Symptoms may not appear for anywhere from 10 to 50 years after exposure to asbestos. Common symptoms of pleural mesothelioma include:

Common symptoms of peritoneal mesothelioma include:

What is pleural effusion?

Pleural effusion is the build-up of fluid between the visceral pleura (the membrane lining the lung) and the parietal pleura (the membrane lining the thoracic wall). The extra fluid surrounding the lung compresses it and may cause shortness of breath, chest pain, and dry cough.

What is thrombocytosis?

Thrombocytosis is an abnormal and unhealthy increase in platelet production in the blood. Some cancers can cause reactive or secondary thrombocytosis and is exhibited in 60%-90% of mesothelioma patients. Patients with this condition often exhibit no symptoms for a long period of time. However, some may be at risk for blood clot, stroke, or heart attack.

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How is mesothelioma diagnosed?

X-rays, chest and lung function tests, CT scans, and MRI’s are all common methods of obtaining images of suspected regions affected by mesothelioma. Biopsies examined by a pathologist are needed to confirm a diagnosis. If mesothelioma is diagnosed, further staging tests will be performed to gain more information about the patient’s specific case.

What can a chest film show?

An x-ray provides an image of the heart, blood vessels, lungs, and any calcium deposits present in the chest. It can show pericardial and pleural effusion and can detect tumorous nodules. A chest x-ray can also show evidence of pleural plaques, which are benign, often partly calcified, scattered areas of scar tissue on the lining of the lungs. Pleural thickening is scarring throughout the tissue surrounding the lung and may be diffuse throughout the pleura; it can also be detected by x-ray.

Can a chest film show parenchymal pulmonary fibrosis?

Pulmonary fibrosis is a fiber-induced disease of the lung tissue. The stiffness in lung tissue leads to shortness of breath and dry cough and may include fatigue, weight loss, and muscle ache. A chest x-ray is usually not enough to diagnose pulmonary fibrosis so a high-resolution CT scan and pulmonary function test are also needed.

What advantages do PET/CT and MRI imaging techniques have over chest film?

PET (positron emission tomography) scans show changes in certain tissues and/or organs. PET scans can determine the extent of cancer or how the body is responding to treatment. CT scans use a computer to combine multiple x-rays into a two-dimensional cross-sectional image. These images can show the location and extent of the tumor and may indicate any spreading into the lymph nodes. A PET/CT combines both technologies into one scan. It can more accurately determine stage and surgical candidacy.

MRI (magnetic resonance imaging) creates a detailed cross-sectional image of the body and may provide greater contrast between normal tissues and tumor. Both of these techniques provide a clearer and more detailed image than a normal chest x-ray.

Can these imaging techniques show irregularities or tumor involvement in chest wall, pericardium, diaphragm, and lymph nodes?

CT scans can show chest wall and pericardium involvement, but MRIs are generally more accurate in assessing lymph node and/or diaphragm involvement. PET and PET/CT scans are considered the best images to determine staging and surgical candidacy and to track the effects of treatment.

What can you learn from cytology?

Cytology is a diagnostic method that analyzes fluid samples taken from the body. Cytology tests detect presence of disease (i.e. cancer) and classify the findings. A pathologist examines cell samples under a microscope for abnormalities that may indicate cancer. A cytology specimen usually is easier to obtain and causes less discomfort to the patient than a tissue biopsy. Addition, cytology is generally safer and less costly. In many cases, cytology fluid is just as accurate as tissue biopsy, but sometimes the latter is more precise and may often be used to confirm cytology results.

How is a thoracentesis performed?

In this procedure, a needle is inserted through the chest wall to remove fluid from the pleural space (between the lungs and the chest wall). Thoracentesis is a relatively safe procedure, and is used to collect sample fluid to aid in diagnosis. It may also relieve some symptoms due to pleural effusion.

How is a paracentesis performed?

Similar to a thoracentesis, a paracentesis removes peritoneal fluid. In this procedure, a needle is inserted through the belly to draw out the fluid. The sample is then analyzed in the lab for diagnosis of infection or cancer. Paracentesis may also relieve pain or other symptoms caused by the accumulation of fluid.

How is a needle biopsy performed?

There are two types of needle biopsy. One is called fine needle aspiration, in which a small amount of fluid is drawn out using a thin needle and a syringe. The other is called core biopsy and removes a small cylinder of tissue using a larger needle.

Can a needle biopsy help determine the cell type of the tumor?

A needle biopsy can be inadequate to determine cell type because of the unreliability of fluid diagnosis. An open pleural biopsy may be recommended for positive cell type diagnosis.

How is a bronchoscopy performed?  

This is a diagnostic procedure in which the throat, larynx, trachea, and lower airways are examined using a viewing instrument called a bronchoscope which is inserted through the nose or mouth. A flexible bronchoscope is a long, lighted tube which gives a view of the upper airways but also allows tissue biopsy.

A rigid bronchoscope usually requires general anesthesia and uses a straight metal tube. This may be used when there is bleeding or obstruction in the airway or if a larger tissue sample is needed. Bronchoscopy will look for abnormal areas and identify the cause of any airway problems, and it may also take tissue samples for lab analysis.

What is immunohistochemical staining?

This technique is used to detect disease markers for various cancers in a biopsy. A sample of cells is collected. If abnormal, these cells will have specific antigens. The particular antibodies for these substances are marked for visibility then mixed with the sample. In this way, the disease marker can be identified by the antigen-antibody interaction.

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How is mesothelioma staged?

The stage of mesothelioma reflects its progression. Knowing the stage of mesothelioma may indicate which treatment option is best. Currently many different staging systems exist for pleural mesothelioma but none exist for peritoneal mesothelioma. Different staging systems emphasize various areas of progression from the lymph nodes to tumor size. Talk to your doctor about the importance of your stage and what that means for treatment. Then, seek a second opinion from another doctor regarding your potential treatment options.

The TNM System

The TNM system combines information about the tumor size (T), the lymph nodes (N), and metastasis (M) to track the progression of disease. First, a number is assigned to each of these three variables, then the variables are grouped to give the overall stage. The stages are characterized as follows:

Stage I- Tumor involvement in the left or right pleura lining the chest, possible limited involvement of lung, pericardium, or diaphragm, no lymph node involvement

Stage II- Tumor has spread from lining of chest to outer lining of the lung, diaphragm or the lung itself, no lymph node involvement or metastasis to distant sites

Stage III- Tumor spread from lining of chest to outer lining of the lung, diaphragm or the lung itself, possible involvement in muscle or other organs, possible nearby lymph node involvement, no distant metastases

Stage IV- Extensive tumor spreading and/or extensive lymph node involvement, includes metastases to distant sites

The Butchart System

Another method of staging is called the Butchart system which is the oldest staging system and is similar to the TNM system.

Stage I- Tumor involvement in left or right pleura and possibly diaphragm

Stage II- Tumor spread to chest wall, or esophagus, heart or pleura on both sides

Stage III- Tumor spread to lining of abdominal cavity, lymph node involvement

Stage IV- Evidence of distant metastasis or spread through bloodstream

The Brigham System

A third, newer method is the Brigham system which classifies mesothelioma into four stages mainly according to tumor resectability, that is the ability for the tumor to be removed surgically, and lymph node involvement.

Stage I- Resectable tumor, no lymph node involvement

Stage II- Resectable tumor, lymph node involvement

Stage III- Unresectable tumor that has spread into chest wall, heart, diaphragm and/or peritoneum, possible lymph node involvement

Stage IV- Unresectable, distant metastases

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How is mesothelioma treated?

Surgery, radiation, and chemotherapy are the most common forms of cancer treatment. Surgical resection of a mesothelioma tumor can either be accomplished through an extra-pleural pneumonectomy (EPP) where the entire affected lung and sacs are removed or through a less radical pleurectomy decortication (P/D) where only the affected lining is removed leaving the lung in place. Much debate and research exists regarding these two methods of surgical resection.

Other forms of surgical treatment options include a pleurodesis where a sclerosing agent such as talc powder is injected into the chest to prevent further fluid accumulation. Surgery with hyperthermic chemotherapy is another option where heated chemotherapy agents are washed through the incision to eradicate remaining mesothelioma cells.

Chemotherapy and radiation are also frequently administered for mesothelioma patients. Most patients undergo chemotherapy using a combination of pemetrexed (Alimta) and carboplatin (Cisplatin). Onconase is another chemotherapy agent frequently used.

Beyond this, a thoracentesis or paracentesis may be performed to remove fluid build up around the cancerous region. Many clinical trials are in progress throughout the nation to study other avenues of treatment.

What are the available methods for controlling a pleural effusion?

Talc pleurodesis is a palliative, not curative, method of relieving symptoms caused by pleural effusion. In this surgical procedure, the space between the layer of tissue surrounding the lungs and lining the chest wall is eliminated by creating inflammation to join the tissues together. In this way, it does not allow any space for fluid build-up.

What is the difference between a talc pleurodesis and a chemical pleurodesis?

Chemical pleurodesis is only given during a radical surgery. Rather than using talc, a different chemical is used as the irritant to join the pleural tissues together.

What are the surgical options for treating mesothelioma?

Thoracoscopy with pleurodesis- a procedure using a thoracoscope to look inside the chest cavity. During this procedure, a pleurodesis may be performed to help alleviate chest pain and shortness of breath due to pleural effusion.

Pleurectomy/decortication (P/D) - a lung-sparing surgery which involves the removal of the membrane lining the thoracic wall and decortication of the membrane lining the lung. Part of the diaphragm and/or the pericardium may also be removed, depending on the extent of the tumor.

Extra-pleural pneumonectomy (EPP) - a surgery which removes one lung and part of the membrane lining the thoracic wall. It also removes the diaphragm and the pericardium.

What radiation therapy is available to mesothelioma patients?

Radiation is often used as an adjuvant therapy to kill any remaining cancer cells after surgery. It may also be used as the main therapy for patients who are not surgical candidates. There are three main types of radiation procedures for mesothelioma patients: Intensity Modulated Radiation Therapy (IMRT), Radiofrequency Catheter Ablation (RFA), and Interventional Radiology (IR).

IMRT uses very small beams to target a tumor from many angles. Radiation is generally delivered in treatments over four to eight weeks, and the amount of radiation depends on the size, location, and type of cancer as well as the patient’s general health and concurrent medical therapies he or she is receiving.

In contrast, RFA is a procedure in which a thin tube or needle is inserted through the skin to the site of the cancer. Hot chemotherapy agents are delivered through this catheter to target the affected area with minimal damage to the surrounding healthy structures.

Finally, in IR procedures, the treatment tools are inserted through a small nick in the skin, which generally does not require stitches or anesthesia. Radiation can be delivered as a surgical procedure called intra-operative catheter ablation. However, RFA and IR are generally less risky and patients can resume normal activities more quickly afterward.

What chemotherapies are available to mesothelioma patients?

The most common chemotherapy treatment uses Alimta with Cisplatin. Both are cytotoxic chemotherapy drugs which block the growth of tumors. This treatment is typically administered every three weeks in which Alimta is given by IV first, followed by Cisplatin thirty minutes later.

Should chemotherapy be administered before, during or after surgery?

Chemotherapy is not always used in conjunction with surgery. However, if it is used, it is generally administered after surgery.

Can survival rates be affected by additional therapy?

Surgery is often followed by radiation, chemotherapy, or both. Additional treatments are used to try to eliminate any microscopic fragments of cancer left behind by surgery.

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