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What is mesothelioma?
This was my initial question when I first heard of the disease.
Having never known a thing about it, I decided to do some research.
My thanks for this information from
http://www.mesotheliomaweb.org
What is Mesothelioma?
The National Cancer Institute states that: "Malignant mesothelioma, a
rare form of cancer, is a disease in which cancer (malignant) cells are found in
the sac lining the chest (the pleura), the lining of the abdominal cavity (the
peritoneum) or the lining around the heart (the pericardium)."
How do you get Mesothelioma?
Most people with malignant mesothelioma have worked on jobs where they
breathed asbestos. Others have been exposed to asbestos in a household
environment, often without knowing it.
How much exposure does it take to get the disease?
An exposure of as little as one or two months can result in
mesothelioma 30 or 40 years later.
How long does it take after exposure for the disease to show up?
People exposed in the 1940s, 50s, 60s, and 70s are now being diagnosed
with mesothelioma because of the long latency period of asbestos disease.
Pathology and The Role of Pathologists in the Diagnostic Process
Pathology, or the scientific study of cells, tissue, or fluid taken from the
body is an integral part of a mesothelioma diagnosis. Most hospitals have their
own pathology labs staffed by board-certified pathologists and licensed
technologists. The importance of pathological diagnosis can not be
underestimated, since the course of treatment is dependent upon an accurate
diagnosis.
To make a diagnosis, pathologists examine tissue under a microscope, and
based on established criteria, make a determination of benign vs. malignant
cells. Subsequently, the type of cancer is determined. Although most
pathologists have a general expertise of various diseases, a small number
acquire training in a subspecialty, such as mesothelioma. These are physicians
who have received world-wide recognition as premier experts, and have achieved
high acclaim for their research, published articles and abstracts, and teaching.
For a list of expert pathologists in the field of mesothelioma diagnosis, please
call the MW toll free at 1-877-367-6376 or fill in the form at the bottom of
this page specifying your request.
MESOTHELIOMA SYMPTOMS
The early symptoms of mesothelioma are generally non-specific, and may lead
to a delay in diagnosis. Sometimes resembling viral pneumonia, pleural
mesothelioma patients may present with shortness of breath, chest pain and/or
persistent cough; some patients show no symptoms at all. A chest x-ray may show
a build-up of fluid or pleural effusion (discussed below). The right lung is
affected 60% of the time, with involvement of both lungs being seen in
approximately 5% of patients at the time of diagnosis. Less common symptoms of
pleural mesothelioma include fever, night sweats and weight loss. Symptoms of
peritoneal mesothelioma may include pain or swelling in the abdomen due to a
build-up of fluid, nausea, weight loss, bowel obstruction, anemia or swelling of
the feet.
PLEASE KEEP IN MIND THAT THESE SYMPTOMS MAY BE CAUSED BY MESOTHELIOMA OR BY
OTHER LESS SERIOUS CONDITIONS. ONLY A DOCTOR CAN MAKE A DEFINITIVE DIAGNOSIS.
Pleural Effusion
One of the most common symptoms of mesothelioma is a pleural effusion, or an
accumulation of fluid between the parietal pleura (the pleura covering the chest
wall and diaphragm) and the visceral pleura (the pleura covering the lungs).
Both of these membranes are covered with mesothelial cells which, under normal
conditions, produce a small amount of fluid that acts as a lubricant between the
chest wall and the lung. Any excess fluid is absorbed by blood and lymph vessels
maintaining a balance. When too much fluid forms, the result is an effusion.
Types
Pleural effusion is broken down into two categories, transudates and
exudates. A transudate is a clear fluid that forms not because the pleural
surfaces are diseased, but because of an imbalance between the normal production
and removal of the fluid. The most common cause of transudative fluid is
congestive heart failure. An exudate, which is often cloudy and contains many
cells and proteins, results from disease of the pleura itself, and is common to
mesothelioma. To determine whether a fluid is a transudate or exudate, a
diagnostic thoracentesis, in which a needle or catheter is used to obtain a
fluid sample, may be conducted.
Symptoms
As the volume of fluid increases, shortness of breath, known as "dyspnea",
and sometimes pain, ranging from mild to stabbing, may occur. Some patients may
experience a dry cough. When the doctor listens to the patient�s chest with a
stethoscope, normal breath sounds are muted, and tapping on the chest will
reveal dull rather than hollow sounds.
Diagnosis
Diagnosis of pleural effusion is usually accomplished with a simple chest
x-ray, although CT scans or ultrasound may also be used. A special x-ray
technique, called a lateral decubitus film, may be used to detect smaller
effusions or to enable the physician to estimate of the amount of fluid present.
If the underlying cause of the effusion is readily apparent (such as in the case
of severe congestive heart failure), sampling of the fluid may not be necessary,
however, because pleural effusion may be symptomatic of a number of disease
processes from benign to malignant, a fluid sample is generally taken.
Diagnostic thoracentesis, in which cells are extracted from the pleural cavity,
is commonly done when the possibility of mesothelioma exists, however, in up to
85% of cases, the fluid tests negative or inconclusive even though cancer is
present. It is ultimately a needle biopsy of the pleura (lining of the lung) or
an open surgical biopsy which confirms a mesothelioma diagnosis.
Treatment
Pleural effusion caused by heart failure or infection can usually be resolved
by directing treatment at the cause, however, when testing has realized no
diagnosis, and fluid continues to build or recur, doctors may recommend chest
tube drainage and chemical pleurodesis. Chemical pleurodesis is a technique in
which a sclerosing agent is used to abrade the pleural surfaces producing an
adhesion between the parietal and visceral pleurae. This will prevent further
effusion by eliminating the pleural space. Talc appears to be the most effective
agent for pleurodesis, with a success rate of nearly 95%. It is highly effective
when administered by either poudrage or slurry. Poudrage is the most widely used
method of instilling talc into the pleural space. Before spraying the talc, the
medical team removes all pleural fluid to completely collapse the lung. After
the talc is administered, they inspect the pleural cavity to be sure the talc
has been evenly distributed over the pleural surface. Some doctors prefer to use
talc mixed with saline solution which forms a wet slurry that can roll around
the pleural cavity.
MESOTHELIOMA DIAGNOSIS
How is mesothelioma diagnosed?
A diagnosis of mesothelioma is most often obtained with careful assessment of
clinical and radiological findings in addition to a confirming tissue biopsy.
Click here for typical
mesothelioma symptoms. A review of the patient's medical history, including
history of asbestos exposure is taken, followed by a complete physical
examination, x-rays of the chest or abdomen, and lung function tests. A CT scan
or MRI may also be done at this time. If any of these preliminary tests prove
suspicious for mesothelioma; a biopsy is necessary to confirm this diagnosis.
Imaging Techniques and Their Value in Diagnosing and Assessing Mesothelioma
There are several imaging techniques which may prove useful when mesothelioma
is suspected due to the presence of pleural effusion combined with a history of
occupational or secondary asbestos exposure. While these imaging techniques can
be valuable in assessing the possibility of the cancer, definitive diagnosis is
still most often established through fluid diagnosis or tissue biopsy.
Some of the most commonly used imaging methods include:
� X-ray
A chest x-ray can reveal pleural effusion (fluid build-up) which is confined
to either the right (60%) or left (40%) lung. On occasion, a mass may be seen.
Signs of prior non-cancerous asbestos disease, such as pleural plaques or
pleural calcification, or scarring due to asbestosis may also be noted.
� Computed Tomography (CT)
CT scans are also able to define pleural effusion, as well as pleural
thickening, pleural calcification, thickening of interlobular fissures, or
possible chest wall invasion. CT, however, is not able to differentiate
between changes associated with benign asbestos disease (pleural disease), or
differentiate between adenocarcinoma of the lung which may have spread to the
pleura verses mesothelioma. CT scans may also be valuable in guiding fine
needle aspiration of pleural masses for tissue diagnosis.
� Magnetic Resonance Imaging (MRI)
MRI scans are most often used to determine the extent of tumor prior to
aggressive treatment. Because they provide images in multiple planes, they are
better able to identify tumors as opposed to normal structures. They are also
more accurate than CT scans in assessing enlargement of the mediastinal lymph
nodes (those lymph nodes which lie between the two lungs), as well as a clear
diaphragmatic surface, both of which play an important role in surgical
candidacy.
� Positron Emission Tomography (PET)
PET imaging is now becoming an important part of the diagnosis and
evaluation of mesothelioma. While PET scans are more expensive than other
types of imaging, and are not always covered under insurance, they are now
considered to be the most diagnostic of tumor sites, as well as the most
superior in determining the staging of mesothelioma.
Click here for further
explanation of PET scans.
A needle biopsy of the mass, or the removal and examination of the fluid
surrounding the lung, may be used for diagnosis, however, because these samples
are sometimes inadequate as far as determining cell type (epithelial,
sarcomatous, or mixed) or because of the unreliability of fluid diagnosis, open
pleural biopsy may be recommended. In a pleural biopsy procedure, a surgeon will
make a small incision through the chest wall and insert a thin, lighted tube
called a thoracoscope into the chest between two ribs. He will then remove a
sample of tissue to be reviewed under a microscope by a pathologist. In a
peritoneal biopsy, the doctor makes a small incision in the abdomen and inserts
a peritoneoscope into the abdominal cavity.
Once mesothelioma is suspected through imaging tests, it is confirmed by
pathological examination. Tissue is removed, put under the microscope, and a
pathologist makes a definitive diagnosis, and issues a pathology report. This is
the end of a process that usually begins with symptoms that send most people to
the doctor: a fluid build-up or pleural effusions, shortness of breath, pain in
the chest, or pain or swelling in the abdomen. The doctor may order an x-ray or
CT scan of the chest or abdomen. If further examination is warranted, the
following tests may be done:
For pleural mesothelioma the doctor may look inside the chest cavity with a
special instrument called a thoracoscope. A cut will be made through the chest
wall and the thoracoscope will be put into the chest between two ribs. This
test is usually done in a hospital with a local anesthetic or painkiller.
If fluid has collected in your chest, your doctor may drain the fluid out
of your body by putting a needle into your chest and use gentle suction to
remove the fluid. This is called thoracentesis.
For peritoneal mesothelioma the doctor may also look inside the abdomen
with a special tool called a peritoneoscope. The peritoneoscope is put into an
opening made in the abdomen. This test is usually done in the hospital under a
local anesthetic.
If fluid has collected in your abdomen, your doctor may drain the fluid out
of your body by putting a needle into your abdomen and using gentle suction to
remove the fluid. This process is called paracentesis.
If abnormal tissue is found, the doctor will need to cut out a small piece
and have it looked at under a microscope. This is usually done during the
thoracoscopy or peritoneoscopy, but can be done during surgery.
Knowing the stage is a factor in helping the doctor form a treatment plan.
Mesothelioma is considered localized if the cancer is confined to the pleura, or
advanced if it has spread beyond the pleura to other parts of the body such as
the lungs, chest wall, abdominal cavity, or lymph nodes.
More on
mesothelioma
diagnosis and stages of the disease.
MESOTHELIOMA DIAGNOSIS QUESTIONS
Doctor-Patient Communication
An open line of communication between a patient and his or her physician is
vital when dealing with a serious disease such as mesothelioma. There will be
many questions regarding treatment, whether palliative or aggressive, choices to
deal with, and life issues to confront. Being informed and proactive in your
care will give you a sense of empowerment.
Although most physicians have limited time to spend with each patient at
appointments, it is important to address issues as they occur and resolve them
to the satisfaction of all parties involved. Initially, this may mean going to
your appointment with a list of symptoms or concerns, or questions regarding
specific tests that are recommended. Once mesothelioma has been diagnosed, you
may have questions regarding treatment options.
Most questions from patients stem from an initial diagnosis of mesothelioma
and subsequent treatment options. Following are some frequently asked questions
regarding these two important issues.
What Is My Diagnosis?
There are three types of mesothelioma. Pleural mesothelioma is a cancer of
the lining of the lung (pleura), peritoneal mesothelioma is a cancer of the
lining of the abdominal cavity (peritoneum), and pericardial mesothelioma is a
cancer of the lining surrounding the heart (pericardium). Sub-types (or cell
types) of mesothelioma are epithelioid (the most common, and considered the most
amenable to treatment), sarcomatous (a much more aggressive form), and biphasic
or mixed (a combination of both of the other cell types).
The structural appearance of cells under the microscope determine the cell or
sub-type of mesothelioma. Epithelioid is the least aggressive; sarcomatoid, the
most aggressive. The biphasic or mixed cell type shows structural elements of
both of the other two.
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Epithelioid
mesothelioma tissue
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Sarcomatoid
mesothelioma tissue
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Biphasic
mesothelioma tissue
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MESOTHELIOMA STAGES
Treatment options are often determined by the stage of mesothelioma a patient
is in. There are three staging systems currently in use for pleural mesothelioma
and each one measures somewhat different variables; peritoneal mesothelioma is
not staged.
The oldest staging system and the one most often used is the Butchart
System which is based mainly on the extent of primary tumor mass and
divides mesotheliomas into four stages. The more recent TNM system
considers variables of tumor in mass and spread, lymph node involvement, and
metastasis. The Brigham System is the latest system and stages
mesothelioma according to resectability (the ability to surgically remove) and
lymph node involvement.
Butchart System � extent of primary tumor mass
- Stage I: Mesothelioma is present in the right or left
pleura and may also involve the diaphragm on the same side.
- Stage II: Mesothelioma invades the chest wall or involves
the esophagus, heart, or pleura on both sides. Lymph nodes in the chest may
also be involved.
- Stage III: Mesothelioma has penetrated through the
diaphragm into the lining of the abdominal cavity or peritoneum. Lymph nodes
beyond those in the chest may also be involved.
- Stage IV: There is evidence of metastasis or spread
through the bloodstream to other organs.
TNM System -- variables of T (tumor), N (lymph nodes), M
(metastasis)
- Stage I: Mesothelioma involves right or left pleura and
may also have spread to the lung, pericardium, or diaphragm on the same side.
Lymph nodes are not involved.
- Stage II: Mesothelioma has spread from the pleura on one
side to nearby lymph nodes next to the lung on the same side. It may also have
spread into the lung, pericardium, or diaphragm on the same side.
- Stage III: Mesothelioma is now in the chest wall, muscle,
ribs, heart, esophagus, or other organs in the chest on the same side with or
without spread to lymph nodes on the same side as the primary tumor.
- Stage IV: Mesothelioma has spread into the lymph nodes in
the chest on the side opposite the primary tumor, or extends to the pleura or
lung on the opposite side, or directly extends into organs in the abdominal
cavity or neck. Any distant metastases is included in this stage.
Brigham System: (variables of tumor resectability and nodal
status)
- Stage I: Resectable mesothelioma and no lymph node
involvement
- Stage II: Resectable mesothelioma but with lymph node
involvement
- Stage III: Unresectable mesothelioma extending into chest
wall, heart, or through diaphragm, peritoneum; with or without extrathoracic
lymph node involvement
- Stage IV: Distant metastatic disease
How Was This Diagnosis Determined, and How Accurate Were the Tests?
Although you probably took many different tests leading up to your diagnosis,
a tissue biopsy is normally the final determining factor. Following are some
tests your doctor may recommend, and what may or may not be concluded from these
tests.
- X-rays, CT scans, and MRIs - On conventional x-ray film, mesothelioma
appears as a markedly thickened, nodular, irregular pleural-based mass which
covers the pleural surface. The tumor often encompasses the involved lung, but
is only rarely seen bilaterally. Chest wall, diaphragmatic, and mediastinal
invasion may be seen in advanced cases. Moderate to large pleural effusion is
often noted on the affected side. On CT scan, pleural thickening greater than
1 cm can be identified in over 90% of cases; thickening which extends into the
interlobular fissure is seen in 85% of cases. Absence of pleural thickening
does not preclude mesothelioma, and at times, the only CT finding is that of
pleural effusion.
- Cytology - Testing of the pleural fluid for malignant cells is considered
to have limited value in diagnosing mesothelioma. Negative or inconclusive
readings account for nearly 85% of all fluid tested. Even with a positive
fluid report, many doctors prefer to perform a confirming tissue biopsy as
long as it does not compromise the patient's health.
- Needle Biopsy - In this test, done under local anesthetic, a large hollow
needle is inserted through the skin and into the chest cavity. The needle is
then rotated, and as it is taken out, tissue samples are collected. Because of
the small sample size of the tissue, this type of biopsy is considered to be
only 25-60% accurate in diagnosing mesothelioma. Because tumor seeding may
occur along the needle tract in approximately 20% of patients, local radiation
therapy may be used in conjunction with this test.
- Open biopsy - This type of biopsy is considered to be the most accurate
for mesothelioma diagnosis, and is the procedure of choice because it affords
the pathologist a larger tissue sample.. It is done in a hospital under
general anesthetic. As with a needle biopsy, local radiation may be used
because of the possibility of tumor seeding.
Can I Be Treated by the Doctor Who Diagnosed My Mesothelioma?
If the doctor who diagnosed your mesothelioma is your primary physician, he
will most likely refer you to a local oncologist for treatment. The oncologist
may offer what he or she feels are the best treatment options, or, if their
knowledge of this disease is limited, may suggest you seek out a doctor who
specializes in mesothelioma. Most often these physicians are located at larger,
teaching hospitals. These facilities are ranked as state-of-the-art cancer
centers, and are highly respected for their patient care and innovative cancer
treatments. If your choice of treatment involves a radical surgical procedure or
a clinical trial involving new, as yet unproven drugs, these facilities may be
best for you. If your treatment involves an already-approved, standard form of
chemotherapy, this can be carried out locally.
What Treatment Options Will I Be Offered?
Treatment options may vary according to the age and over-all health of the
patient, and the extent of the disease. It is important to be informed of all
available options for your particular case, so that you can make decision on the
option you feel most comfortable with. Surgery, chemotherapy, and clinical
trials, as well as new approaches such as photodynamic therapy, immunotherapy,
and gene therapy may be offered. Speak openly with your doctor regarding
suggested procedures. Questions may include:
- Why is this procedure best for me?
- What does the procedure entail?
- What are the advantages/disadvantages of this treatment (i.e, will this
procedure limit my eligibility for other treatments)?
- What are the possible risks or adverse side effects?
- What are the response, survival, and mortality rates associated with this
procedure?
Is Palliative Treatment an Option?
In some circumstances, age, contributing health problems, or advanced disease
may make aggressive treatment impossible. In these cases, palliative care (that
which treats the symptoms, but not the disease itself) may be appropriate. If
you opt for palliative care, it is doubly important to communicate fully with
your doctor. Many symptoms of mesothelioma can be alleviated or substantially
lessened if you are completely open with your doctor. Each time you have an
appointment, tell your doctor how you feel, what discomfort you are
experiencing, and your level of pain. A good doctor should be willing to address
your questions and concerns.
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