Which treatment for mesothelioma?

The choice of treatment first depends on which type of mesothelioma you have been diagnosed with. Please choose the information that is right for you

Pleural mesothelioma treatment

Your choice of treatment will depend on a number of factors including
The stage of your cancer
Any other medical conditions you may have
Your general fitnessUnfortunately mesothelioma can be very difficult to treat. Nearly all treatment is aimed at controlling the diseaes for as long as possible and keeping symptoms under control. Mesothelioma can be treated with

Chemotherapy
Radiotherapy
Surgery

Doctors and researchers are working to improve treatment all the time. You may be offered treatment as part of a clinical trial and not as a standard treatment. The results of the trials will be used to improve treatment in the future. There is information about taking part in a clinical trial in CancerHelp UK.

Mesothelioma treatment is designed to treat the immediate area of the pleural mesothelioma or the whole body. Whole body treatments are called systemic treatments. Localised treatments include surgery and radiotherapy. Systemic treatments act on cancer cells no matter where they may be in the body and include chemotherapy.

Chemotherapy

Chemotherapy uses anti-cancer drugs, which are usually injected into a vein. Depending on the type of chemotherapy drugs used, you may have treatment weekly, or every 2 to 3 weeks.

Chemotherapy for mesothelioma is given to slow down the cancer and to control symptoms. If you have had surgery, you may be given chemotherapy afterwards. This is called adjuvant chemotherapy. It is given to delay the return of the cancer as much as possible.Chemotherapy can be used to control symptoms in more advanced mesothelioma.

The treatment may also help to slow down the growth of the cancer. There is a clinical trial that is looking into giving chemotherapy in mesothelioma that cannot be operated on. The trial is comparing having chemotherapy to not having chemotherapy to see if chemotherapy can control symptoms and improve quality of life.

Whlie they are open and recruiting patients, both these trials will be on our clinical trials database. To find mesothelioma trials, click on the blue clinical trials button to the left of your screen and choose 'Lung: mesothelioma' from the drop down menu.

Radiotherapy

Radiotherapy can be used to try to slow down the disease or to control symptoms. You may have radiotherapy after surgery for stage 1 mesothelioma to try to slow down the return of the cancer as much as possible. Radiotherapy given after surgery is sometimes called adjuvant radiotherapy. Radiotherapy may also be used for stage 2, 3, or 4 mesothelioma. It is given to slow the cancer down, or to control symptoms. The length of your treatment will depend on the type and size of your cancer and on why you are being treated. Radiotherapy is sometimes given after fluid has been drained from around your lung. This is to try to stop new growths of mesothelioma developing on your chest wall.

Surgery

Surgery can be used to remove localised mesothelioma, or to take out as much as possible so that other treatments have a better chance of working. This is sometimes called de-bulking. There are 2 major operations that can be done:

Pleurectomy

Extrapleural pneumonectomy

Pleurectomy This means removing the pleura. The lung is left behind. The pleural space around it is sealed so that no further fluid can collect there. If you have stage 1 mesothelioma, it may be done to remove the cancer. If you have a more advanced stage, it will not cure you but can help to relieve symptoms such as pain and fluid collection around the lung (pleural effusion). Removing as much of the cancer as possible may also help other treatments to work more effectively, for example, chemotherapy.

Extrapleural pneumonectomy (EPP)

This is extensive surgery, which is not suitable for everyone with mesothelioma. It can be done if you have mesothelioma that is up to TNM stage T3,N1. This means stage 1 mesothelioma as well as stage 2 mesothelioma and some stage 3 mesothelioma. It will not cure mesothelioma, but may slow down the growth of the disease and give people better quality of life for longer. Pneumonectomy means removing the lung. Extrapleural means that the pleura, diaphragm, covering of the heart (pericardium) are removed as well on the side affected by mesothelioma.

This operation is only possible if you are fit enough and have good heart and lung function. If your heart and lung function is already poor, the operation may do you more harm than good.

There is a trial soon to start that is looking into extrapleural pneumonectomy. All patients will have some form of surgery, chemotherapy and radiotherapy. Half will have extra pleural pneumonectomy and an intensive course of radiotherapy. This trial will help to show if going through the trauma of major surgery is helpful or not in the long run in delaying the disease or in controlling symptoms. It will also show whether EPP is any better than other types of operation at helping to control mesothelioma.

Supportive care (Palliative care)

Mesothelioma is often diagnosed when it is quite advanced. Some people with very advanced disease may be too ill to cope with chemotherapy, radiotherapy, or surgery. But they can still be given treatment to try to relieve symptoms such as pain, breathing problems and weight loss. Your care will be managed by a palliative care team. This is a team of doctors and nurses who are expert in controlling symptoms of advanced cancer. The team may also include a physiotherapist and a dietician.

If you are having trouble with fluid collecting around your lungs, you may be offered treatment to try to stop this from happening. Pleurectomy is one option. Another is thoracocentesis. This is often called a pleural tap.

The fluid that has collected in the pleural space is drained off. Often sterile talc or an antibiotic is put in to seal the space and stop the fluid collecting again. This is called pleurodesis.

Peritoneal mesothelioma treatment

Your choice of treatment will depend on a number of factors

• The stage of your cancer
• Any other medical conditions you may have
• Your general fitness

Unfortunately mesothelioma does not always respond to cancer treatments. Doctors and researchers are working to improve mesothelioma treatment all the time. You may be offered treatment as part of a clinical trial and not as a standard treatment. The results of the trials will be used to improve treatment in the future. There is information about taking part in a clinical trial in CancerHelp UK.

Mesothelioma treatment is designed to treat the immediate area of the primary mesothelioma growth or the whole body. Whole body treatments are called systemic treatments. Localised treatments include surgery and radiotherapy. Systemic treatments act on cancer cells no matter where they may be in the body and include chemotherapy.

Surgery

It is often not possible to operate on peritoneal mesothelioma. But if it is found very early, it may be possible to remove it with surgery. The operation is called a peritonectomy. This means removing the peritoneum – the lining of the abdomen where the mesothelioma has started growing.

Chemotherapy

Chemotherapy uses anti-cancer drugs, which are usually injected into a vein. For mesothelioma, chemotherapy may be given directly into the abdomen. Depending on the type of chemotherapy drugs used, this treatment can be given weekly or every two to three weeks. Usually the treatment is given as an outpatient. Chemotherapy for peritoneal mesothelioma is given to help control symptoms and to try to slow the cancer down.

Supportive care (Palliative care)Unfortunately peritoneal mesothelioma is often diagnosed when it is quite advanced. Some people may be too ill to cope with intensive chemotherapy. But you can still have treatment to try to relieve symptoms such as pain, weight loss and other symptoms such as fluid in the abdomen.

With more advanced peritoneal mesothelioma, fluid may collect inside your abdomen. If too much fluid collects, it makes your abdomen swell. This can be uncomfortable and heavy.

You can have the fluid drained off. This is called abdominal paracentesis. It is sometimes called an ascitic tap.

Your care will be managed by a palliative care team. This is a team of doctors and nurses who are expert in controlling the symptoms of advanced cancer. The team may also include a physiotherapist and a dietician.

The stages of mesothelioma

The staging of pleural mesothelioma is different to the staging of peritoneal mesothelioma.


Pleural mesothelioma stages
There are two main staging systems in use for pleural mesothelioma. These are called the TNM system and the Brigham system. In the UK, the system that is mostly commonly used is the TNM system. Specialists generally don't use the Brigham system any more, but we've left it in here for now in case your own doctor refers to it.

The TNM system
This is also sometimes called the International Mesothelioma Interest Group staging system.

The TNM system is the staging system most commonly used in cancer staging generally. The TNM system describes the extent of the primary tumour (T), the absence or presence of cancer in nearby lymph nodes (N), and the absence or presence of distant metastases (M).

Once the TNM categories have been decided, this information is grouped together to give the stage. Stage 1 is the earliest stage and stage 4 is the most advanced stage.


Stage 1 mesothelioma affects one layer of the pleura only. It may have grown into the covering of the heart (pericardium) and the diaphragm
Stage 2 mesothelioma has spread to both layers of the pleura on one side of the body only
Stage 3 mesothelioma has spread to the chest wall, food pipe (oesophagus) or lymph nodes on the same side of the chest
Stage 4 mesothelioma has spread via the bloodstream to other organs in the body such as the liver, brain or bone or to lymph nodes on the other side of the chest
The Brigham staging system
This is based on whether the mesothelioma can be removed by surgery and whether the lymph nodes are involved or not. Again there are four stages, which are similar to the TNM system.


Stage 1 mesothelioma can be removed with surgery and there are no lymph nodes containing cancer cells
Stage 2 mesothelioma can be removed with surgery but there are lymph nodes containing cancer cells
Stage 3 mesothelioma cannot be removed with surgery because it has spread into the chest wall, heart, or through the diaphragm into the peritoneum. There may or may not be lymph nodes containing cancer cells
Stage 4 mesothelioma has spread via the bloodstream to other organs in the body such as the liver, brain or bone
Peritoneal mesothelioma stages
There is no established staging system for peritoneal mesothelioma. If your cancer is staged it may be done according to the TNM system. The TNM system is the staging system most commonly used in cancer. The TNM system describes the extent of the primary tumour (T), the absence or presence of cancer in nearby lymph nodes (N), and the absence or presence of distant metastases (M).

Mesothelioma Cell types

Mesothelioma is also grouped according to how the cells look under a microscope. When mesothelioma is grouped this way, there are 3 types

Epitheloid
Sarcomatoid or fibrous
Mixed type (also called Biphasic type)
Between 5 and 7 out of 10 cases (50-70%) of mesothelioma diagnosed are the epitheloid type.

Between 7 and 20 out of every 100 cases (7 – 20%) of mesothelioma diagnosed are sarcomatoid type.

Between 20 and 35 out of every 100 cases (20 – 35%) of mesothelioma diagnosed are mixed and have both epitheloid and sarcomatoid cells.

These types of mesothelioma cells can further divide into other types of cancerous cells called

Clear cell
Small cell
Acinar cell
Tubopapillary cell
With so many different types of cells capable of developing into mesothelioma, it makes it very difficult to diagnose this disease.

Treating mesothelioma

This section tells you about the treatment for mesothelioma. You can choose from the following menu

1.The stages of mesothelioma
2.Statistics and prognosis for mesothelioma
3.Which treatment for mesothelioma?
4.Surgery for mesothelioma
5.Radiotherapy for mesothelioma
6.Chemotherapy for mesothelioma
7.Follow up for mesothelioma
8.What's new in mesothelioma
9.Questions for your doctor about traeating mesothelioma


The staging of pleural mesothelioma is different to the staging of peritoneal mesothelioma.

Pleural mesothelioma stages

There are two main staging systems in use for pleural mesothelioma. These are called the TNM system and the Brigham system. In the UK, the system that is mostly commonly used is the TNM system. Specialists generally don't use the Brigham system any more, but we've left it in here for now in case your own doctor refers to it.

The TNM system
This is also sometimes called the International Mesothelioma Interest Group staging system.

The TNM system is the staging system most commonly used in cancer staging generally. The TNM system describes the extent of the primary tumour (T), the absence or presence of cancer in nearby lymph nodes (N), and the absence or presence of distant metastases (M).

Once the TNM categories have been decided, this information is grouped together to give the stage. Stage 1 is the earliest stage and stage 4 is the most advanced stage.


Stage 1 mesothelioma affects one layer of the pleura only. It may have grown into the covering of the heart (pericardium) and the diaphragm
Stage 2 mesothelioma has spread to both layers of the pleura on one side of the body only
Stage 3 mesothelioma has spread to the chest wall, food pipe (oesophagus) or lymph nodes on the same side of the chest
Stage 4 mesothelioma has spread via the bloodstream to other organs in the body such as the liver, brain or bone or to lymph nodes on the other side of the chest
The Brigham staging system
This is based on whether the mesothelioma can be removed by surgery and whether the lymph nodes are involved or not. Again there are four stages, which are similar to the TNM system.

Stage 1 mesothelioma can be removed with surgery and there are no lymph nodes containing cancer cells
Stage 2 mesothelioma can be removed with surgery but there are lymph nodes containing cancer cells
Stage 3 mesothelioma cannot be removed with surgery because it has spread into the chest wall, heart, or through the diaphragm into the peritoneum. There may or may not be lymph nodes containing cancer cells
Stage 4 mesothelioma has spread via the bloodstream to other organs in the body such as the liver, brain or bone
Peritoneal mesothelioma stages
There is no established staging system for peritoneal mesothelioma. If your cancer is staged it may be done according to the TNM system. The TNM system is the staging system most commonly used in cancer. The TNM system describes the extent of the primary tumour (T), the absence or presence of cancer in nearby lymph nodes (N), and the absence or presence of distant metastases (M).

Diagnose Mesothelioma

This article tells you about tests you may have that can diagnose mesothelioma. You can scroll down the page to read all the information here. Or you can use these links to go straight down to sections on

Seeing your GP
At the hospital
X-rays
CT scan
Thoracoscopy (and biopsy of the pleura)
Fluid drainage (thoracocentesis or abdoparacentesis)
Bronchoscopy
MRI scan
Mediastinoscopy
Laparoscopy (only for suspected abdominal disease)
Difficulty diagnosing mesothelioma
At the GP
Usually you begin by seeing your family doctor who will examine you and ask about your general health. Your doctor will ask you about your symptoms. This will include what they are, when you get them and whether anything you do makes them better or worse.

Your doctor will ask you to lie down for a physical examination. The doctor will feel the area where there is pain or swelling. It may feel tender, or it may be possible to feel a lump. Your doctor will listen to your chest, to see if there are any signs of fluid collecting.

After your examination, your doctor may need to refer you to hospital for tests and X-rays. You may be referred directly to a specialist. Or your GP may send you to hospital for some tests first.

At the hospital
If you see a specialist, you will be asked about your medical history and symptoms. The specialist will then examine you by feeling the area that is painful or swollen. You may be asked to have blood tests to check your general health. Then your tests will be arranged in the out patients department.

If your doctor suspects you may have mesothelioma, you may have quite a few tests. This is because it can be difficult to diagnose. Many of the usual tests used to diagnose lung disease prove negative when used to diagnose mesothelioma. You may have

X-rays
CT scan
Thoracoscopy (and biopsy of the pleura)
Fluid drainage (thoracocentesis or abdoparacentesis)
Bronchoscopy
MRI scan
Mediastinoscopy
Biopsy of the abdominal lining (laparoscopy)
Of these tests, X-ray, CT scan and thoracoscopy are the most important for diagnosing mesothelioma. But of course, at this stage, your specialist doesn't know what's wrong. So you may have a range of tests, particularly as mesothelioma can be difficult to diagnose for sure.

X-ray
You will almost certainly be asked to have a chest X-ray or abdominal X-ray. A chest X-ray can show up fluid collecting around the lung. An abdominal X-ray may show up a swelling or fluid in the abdomen (tummy).

CT scan
This is a computerised scan using X-rays. You may be asked to have a CT scan of your chest or abdomen. A CT scan can show abnormal swellings in body organs or lymph nodes. You may be given an injection of dye called ‘contrast’ before the scan. This helps to make the scan clearer to read. There is more about having a CT scan in the CancerHelp UK section About Cancer Tests.

Thoracoscopy
This is a small operation usually performed by a specialist surgeon. It is done under a general anaesthetic. A small cut (incision) is made in your chest wall and a thoracoscope (a telescope like instrument with a video camera attached) is inserted through the hole. Using forceps the doctor can take a biopsy. This is then sent to a laboratory for testing to see if there are any cancer cells. This can be the only certain way of finding out what's wrong because mesothelioma can be so difficult to diagnose. Other tests may not be conclusive enough.

Fluid drainage
Many people with mesothelioma have fluid around their lungs (a pleural effusion) or in their abdominal cavity (peritoneal effusion).



Fluid build up happens because cancer cells are irritating the pleura or peritoneum. This fluid can cause discomfort in the abdomen or difficulty breathing. If mesothelioma is the cause, it may contain cancer cells. To drain the fluid off, a needle is put into the chest or abdominal cavity and the fluid drained into a bag. A sample of the fluid will be sent to a laboratory for testing to see if contains cancer cells. Your doctor may call this 'thoracocentesis' or pleural aspiration if you are having fluid removed from your chest. If you are having fluid removed from your tummy (abdomen), you may hear your doctor call it an abdoparacentesis or peritoneal aspiration.

Bronchoscopy
This is a test that looks at the inside of the airways. A tube called a bronchoscope is put into the airway. The tube has an eyepiece so that the doctor can see into your airways. Biopsies (samples of tissue and cells) can also be taken during a bronchoscopy. These are sent to a laboratory for testing to see if there are any cancer cells present.




The test is usually done as an outpatient under local anaesthetic. This means you are awake for the test, but your throat has been numbed. Sometimes it is done with a general anaesthetic. If you have an anaesthetic, you may have to stay in hospital overnight. This depends on the time of day the test is carried out and your general health.

MRI scan
This is a scan that uses magnetism to build up a picture of the inside of the body. MRI scans can be better than X-ray or CT scan for looking at the soft tissues of the body. You may be asked to have a chest MRI or an abdominal MRI, depending on which type of mesothelioma you are being investigated for. But MRI isn't a routine test for mesothelioma, so you may not have one at all.

MRI scans can be very noisy and some people who don't like small spaces find them difficult to cope with. Tell your doctor beforehand if you have any of these worries or fears. If you have any metal in your body, you cannot have an MRI scan. There is more about having an MRI scan in the About Cancer Tests section of CancerHelp UK.

Mediastinoscopy
This is a test that examines the mediastinum. This is an area in the centre of your chest containing

The heart
The main blood vessels
Lymph nodes
Sometimes in pleural mesothelioma, the lymph nodes that are in the chest are enlarged.



You have to have a general anaesthetic for this test and so have to stay in hospital for at least one night. The doctor makes a small cut at the base of the neck. He puts a small tube through the cut and into the mediastinum. He can look through this tube to examine the area. He can also take tissue samples, which will be examined under a microscope for cancer cells.

When you wake up, you will have a small dressing over the cut where the tube was put in. Don't be afraid to say if you are feeling sore. The nurses will be happy to give you a painkiller. Once you have got over the anaesthetic, you will be able to go home. This will probably be the day after the test.


Laparoscopy
This is a small operation that may be used to diagnose peritoneal mesothelioma. A tube with a camera and a light is put into your abdomen through a small cut. Your doctor can look inside to see whether there is any sign of cancer. The doctor will take samples (biopsies) of any abnormal looking areas. These will be sent to the laboratory for examination under a microscope. Laparoscopy is done under general anaesthetic. You will have a small wound with a couple of stitches. Sometimes, the camera is put in through more than one cut, so you may have more than one wound.

Difficulty with diagnosis
Mesothelioma can be difficult to diagnose. This is because there are many different types of cells that can make up a mesothelioma tumour. Sometimes it can be very difficult for a pathologist (doctor who looks at cells under a microscope) to decide if the cells or tissue taken from the lungs (pleura) or the abdomen (peritoneum) are a type of mesothelioma. These cells can often look very similar to other types of cancerous cells. For example, pleural mesothelioma can look like other types of lung cancer and peritoneal mesothelioma can look like some types of ovarian cancer. Also, many of the usual tests doctors use to diagnose lung disease prove negative when they use them to diagnose mesothelioma. For these reasons if your doctor suspects you may have mesothelioma, you may have quite a few tests so they can be sure of a correct diagnosis. In some cases, it may even be necessary for you to have surgery in order to find out what's wrong (a surgical biopsy).

Mesothelioma Cell types

Mesothelioma is also grouped according to how the cells look under a microscope. When mesothelioma is grouped this way, there are 3 types

Epitheloid
Sarcomatoid or fibrous
Mixed type (also called Biphasic type)
Between 5 and 7 out of 10 cases (50-70%) of mesothelioma diagnosed are the epitheloid type.

Between 7 and 20 out of every 100 cases (7 – 20%) of mesothelioma diagnosed are sarcomatoid type.

Between 20 and 35 out of every 100 cases (20 – 35%) of mesothelioma diagnosed are mixed and have both epitheloid and sarcomatoid cells.

These types of mesothelioma cells can further divide into other types of cancerous cells called

Clear cell
Small cell
Acinar cell
Tubopapillary cell
With so many different types of cells capable of developing into mesothelioma, it makes it very difficult to diagnose this disease.

Types of mesothelioma

There are 2 main types of mesothelioma

Pleural mesothelioma
Peritoneal mesothelioma
The pleural type grows in the tissues covering the lungs. The peritoneal type grows in the tissue lining the inside of the abdomen (tummy). Pleural mesothelioma is much more common than peritoneal mesothelioma.

Between 7 and 8 out of 10 (70-80%) cases of mesothelioma are pleural mesothelioma. Peritoneal mesothelioma is much less common, making up between 1 and 2 out of every 10 cases (10 - 20%).

Where Mesothelioma cancer can develop in your body?

Mesothelioma cancer can develop in the tissues covering the

Lungs / The pleura
The tissues lining (or covering) the lungs are called the pleura. There are two pleura. These can be called pleural membranes. The gap between them is called the pleural space. The pleura are fibrous sheets. They help to protect the lungs. They produce a lubricating fluid that fills the gap between the two pleura. This helps the lungs to move smoothly in the chest when they are inflating and deflating as we breathe.

Mesothelioma is most often diagnosed in the pleura. This is known as pleural mesothelioma. Because it is so close, pleural mesothelioma can also affect the sheet of tissue covering the heart - the pericardium. Doctors call the pericardium the lining, although it is on the outside of the heart. It protects the heart and allows it to move smoothly within the sac that surrounds it. So it does much the same job for the heart as the pleura do for the lungs.

Abdomen / The peritoneum

The tissue lining the abdomen is called the peritoneum. It helps to protect the contents of the abdomen. It also produces a lubricating fluid. This helps the organs to move smoothly inside the abdomen as we move around.

Mesothelioma of the tissues lining the abdominal cavity in known as peritoneal mesothelioma. It is much less common than pleural mesothelioma.

It is unusual for mesothelioma to spread to other parts of the body. But if it does, it does not usually cause troublesome symptoms.