Mesothelioma

Mesothelioma Staging

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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.

Staging is the term used to describe the extent of a patient's cancer, based on the primary tumor and its spread in the body. It can help the medical team plan treatment, estimate prognosis and identify clinical trials for which the patient may be eligible.

Staging is based on a knowledge of how the cancer develops, from the primary tumor, to the invasion of nearby organs and tissues, to distant spread or metastasis. Staging systems have evolved over time, and they continue to change as scientists learn more about cancer. Some staging systems cover many different types of cancer, while others focus on more specific cancers. The TNM (primary tumor, regional lymph nodes, distant metastasis) is the most common staging system for mesothelioma.

Some elements common to most staging systems are:

* Location of the primary tumor.
* Size and number of the tumors.
* Lymph node involvement.
* Cell type and tumor grade.
* Metastasis.

Many cancer registries, such as the National Cancer Institute's Surveillance, Epidemiology, and End Results Program (SEER) use summary staging, a system used for all types of cancer. Summary staging groups cancer into five main categories:

* In situ - cancer that is present only in the layer of cells in which it began.

* Localized - cancer that is limited to the organ in which it began with no evidence of spread.

* Regional - cancer that has spread from the primary site to nearby lymph nodes or organs.

* Distant - cancer that has spread from the primary site to distant lymph nodes or organs.

* Unknown - cases where not enough information exists to indicate stage.

Several types of testing may be used to help doctors determine stage, and to formulate a treatment plan.

* Physical examinations. The doctor examines the body by looking, feeling and listening to anything out of the ordinary.

* Imaging techniques. Procedures such as x-rays, CT scans, MRIs and PET scans may show the location, size of the tumor and whether the cancer has spread.

* Laboratory tests. Studies of blood, urine, fluid and tissue can provide information about the cancer. Tumor markers, sometime elevated when cancer is present, may provide information.

* Pathology reports. Results of the examination of tissue samples can include information about the size of the tumor(s), extension into adjacent structures, type of cells and grade of the tumor. Results of the examination of cells in fluid, such as that from a mesothelioma-related pleural effusion, may also provide information.

* Surgical reports. Observations about the size and appearance of the tumor(s), lymph nodes and nearby organs.

Staging information should be provided to the patient by his doctor so that potential treatment plans can be discussed. Stage of the mesothelioma, as well as consideration of other factors such as age, health status and the patient's wishes may dictate different treatment options.

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.

New techniques for diagnosis.

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• 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. Further explanation of PET scans.

• CT/PET

For patients who may be candidates for aggressive multimodality treatment (surgery, chemotherapy and radiation), accurate clinical staging is extremely important. Integrated CT/PET imaging provides a relatively new tool in this respect, and has become the imaging technique of choice for determining surgical eligibility. By combining the benefits of CT and PET (anatomic and metabolic information) into a single scan, this technology can more accurately determine the stage of the cancer, and can help identify the best treatment option for the patient. Read about a study of CT-PET imaging in preoperative evaluation of patients with malignant pleural mesothelioma.

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:

Video-Assisted Thoracoscopic Surgery (VATS)

Over the past decade, the use of video-assisted thoracic surgery (VATS) has become one of the most widely used tools in the diagnosis of mesothelioma. Biopsies of the pleural lining, nodules, masses and pleural fluid can now easily be obtained using this minimally invasive procedure, and other therapies such as pleurodesis (talc) for pleural effusions can be done concurrently.While the patient is under general anesthesia, several small incisions or “ports” are made through the chest wall. The surgeon then inserts a small camera, via a scope, into one incision, and other surgical instruments used to retrieve tissue samples into the other incisions. By looking at a video screen showing the camera images, the surgeon is able to complete whatever procedures are necessary

In many cases, this video-assisted technique is able to replace thoracotomy, which requires a much larger incision to gain access to the chest cavity, and because it is minimally invasive, the patient most often has less post-operative pain and a potentially shorter recovery period.

Diagnosis of Mesothelioma (Images)

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An Image of lung thoracoscope

An X-ray Image of the lung

A CT SCAN

Yellow arrows ....the mesothelioma tumour

1. Normal air spaces of rt lung
2. Sections through vertebrae of the spine
3. Normal air spaces of left lung
4. Cross sections through ribs
5. Aorta
6. Spleen
7. Left Kidney
8. Rt Kidney
9. Liver

Diagnosis of Mesothelioma

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Mesothelioma is diagnosed by pathological examination from a biopsy. Tissue is removed, placed 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 buildup around the lungs (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:

Thoracoscopy

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 using 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 using gentle suction to remove the fluid. This is called thoracentesis.

Peritoneoscopy

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.

Biopsy

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.

Unfortunately, in some cases, tumor cells can grow along the tract where the biopsy is taken. This can be minimized with the use of radiation to the area.

source:

www.medicinenet.com

Symptoms of Mesothelioma

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Exercise symptoms: Symptoms related to or triggered by exercise.

chest pain

Persistent cough: Cough that remains or becomes chronic.

Bronchitis: Inflammation of the bronchi as a symptom.

Breathlessness: Breathing difficulty of any kind (or any kind of "shortness of breath") is a potentially life-threatening emergency.

Pleural effusion, or fluid surrounding the lung .

Wheezing: Breathing difficulty with specific wheezing sound.

Fatigue or anemia.

Hoarseness of voice.

Hemoptysis: Where a person coughs up blood.

Weight loss .

Increased abdominal girth.

Distention of the abdomen.

Changes in bowel habits.

Development of lumps under the skin on the abdomen .

Ascites: The presence of serous fluid within the abdominal cavity.
Fever.

Digestive disturbances.

Types of mesothelioma

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Pleural mesothelioma:

Pleural mesothelioma is the main type of mesothelioma that is typically similar to lung cancer. However, there are also other types of mesothelioma affecting the heart (pericardial mesothelioma) and abdomen (peritoneal mesothelioma).

Peritoneal mesothelioma:

Peritoneal mesothelioma is a type of mesothelioma affecting the peritoneum (abdominal membrane).

Pericardial Mesothelioma:

Pericardial mesothelioma, or mesothelioma of the pericardium, is a disease that affects the lining of the heart.

Malignant mesothelioma:

Malignant mesothelioma affects the lining or membranes of certain large cavities in the body. These cavities, called the serous cavities, house certain major organs in the body including the heart, lungs, abdomen and others.

Benign mesothelioma:

Benign mesothelioma refers to any type of mesothelioma that is non-cancerous; Unlike most cancerous mesothelioma cases, benign mesothelioma is not usually related to asbestos.

Sarcomatoid Mesothelioma:

Sarcomatoid mesothelioma accounts for only about 10 to 15 percent of the mesothelioma cancer cells and it is the least common form of mesothelioma. It appears as spindle-shaped pattern of cells that overlap one another, and generally arises from support tissues such as bone, cartilage, muscle, and fat.

Biphasic Mesothelioma:

Biphasic mesothelioma is the second most common type of mesothelioma cancer cell Biphasic mesothelioma, or mixed mesothelioma, contains a mixture of epithelioid and sarcomatoid cells.

Epitheloid mesothelioma .

source:

Mesothelioma
by Bruce W S Robinson (Editor), A Philippe Chahinian (Editor)

Mesothelioma Risk Factors

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Asbestos Exposure
Asbestos exposure is the primary risk factor for mesothelioma. Asbestos is a group of minerals once used in industrial and construction materials, but is now produced in small quantities. Asbestos was once found in products like:

tile and flooring

insulation

door gaskets

roofing materials

cement

plaster of paris

joint compound

textured paint

It is estimated that about 8 million Americans have been exposed to asbestos. It generally takes 20-50 years for mesothelioma symptoms to present themselves after a person is exposed to asbestos.

Smoking and Asbestos Exposure
The combination of tobacco smoking and exposure to asbestos can greatly increase the risk factor for developing mesothelioma. According to the American Cancer Society, no studies currently link smoking alone to mesothelioma.

Radiation

In the past, certain x-rays used a material called thorium doxide. It was later to have been found to cause mesothelioma. Fortunately, it is no longer in use.

Zeolite
Zeolite is a natural occurring mineral in the Turkish region, Anatoli. Zeolite is found in the soil and is very similar to asbestos.

MESOTHELIOMA'S CAUSE

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At some point in our lives, nearly all of us have been exposed to asbestos in the air we breathe and the water we drink; from natural deposits in the earth, and from the deterioration of asbestos products around us. Most of us, however, do not become ill as a result of our exposure. More commonly, those who at some point are diagnosed with asbestos disease, have worked in jobs where more substantial exposure occurred over longer periods of time. Nevertheless, cases of mesothelioma have been documented as the result of lesser exposure, affecting family members of workers who came into contact with asbestos and brought it home on their clothing, skin or hair, or affecting those who lived in close proximity to asbestos manufacturing facilities. Symptoms of asbestos disease usually are not be apparent until decades after exposure.

Asbestos was used commercially in North America as early as the late 1800s, but its use increased dramatically during the World War II era when shipyards produced massive numbers of ships for the war effort. Since that time, asbestos-containing products were used by the construction and building trades, the automotive industry and the manufacturing industry. All told, more than 5,000 products contained asbestos.

For more than 50 years, products containing asbestos remained unregulated, and the manufacturers of those products continued to prosper, knowing full well that many of the millions of workers who came into contact with their products would ultimately suffer as the result of their actions. Finally, in the late 1970s, the Consumer Products Safety Commission banned the use of asbestos in wallboard patching compounds and artificial ash for gas fireplaces because the fiber could easily be released during use. In 1989, the Environmental Protection Agency banned all new use of asbestos, but uses established prior to that time were still allowed. Although awareness of the dangers of asbestos and public concern over the issue have led to a decline in domestic consumption over the years, a total ban on asbestos has not come to fruition. Asbestos is still imported, still used and still dangerous.

Although it is suggested that the number of mesothelioma cases in the U.S. has reached its peak and has begun to drop, a forecast released by the National Cancer Institute's Surveillance, Epidemiology, and End Results Program (SEER), in April, 2003, projected the total number of American male mesothelioma cases from 2003-2054 to be approximately 71,000. This number, however, does not take into consideration events such as the World Trade Center disaster on September 11, 2001, when millions of New Yorkers were potentially exposed to air filled with carcinogenic asbestos particles. The incidence of mesothelioma cases by state and county are shown in these tables. When the latency period for asbestos disease is factored in, cases of mesothelioma will continue to be diagnosed for years to come.

source:

Centers for Disease Control, Occupational Safety and Health Administration, National Cancer Institute

About Mesothelioma

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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 (pericardium)."

What is peritoneal mesothelioma?

Peritoneal mesothelioma is a cancer of the lining of the abdominal cavity. This form of cancer makes up approximately one-fifth to one-third of the total number of mesothelioma cases diagnosed. More on peritoneal mesothelioma.

How do you get malignant 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. More about the different ways in which people have been exposed to asbestos.
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. Mesothelioma cause.

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.

What is the prognosis for malignant mesothelioma?

Like most cancers, the prognosis for this disease often depends on how early it is diagnosed and how aggressively it is treated. Click on Treatment Options to find out more about traditional and new approaches.

Is there any promising research or are there promising drugs for mesothelioma?

Research is being conducted at various cancer centers all over the United States as well as by pharmaceutical companies. To find more about these studies, click on Clinical Trials. To read abstracts of the latest journal articles on mesothelioma research and to access these articles, click on Medical Journal Articles; or Mesothelioma News for news articles. A recent study of Alimta showed patients living much longer with Alitma than other chemotherapy drugs.

Where can I find information on living with mesothelioma?

Mesothelioma Aid is a good website for resource for families dealing with mesothelioma. It includes advice and referrals to other resources for coping with cancer, caregiving, financial challenges, and support groups. Alternatively, contact us here at Mesothelioma Web for help finding resouces for living with this disease.

What kinds of other resources are available for people with malignant mesothelioma?

There are numerous cancer web sites, some specific to mesothelioma. Because they are often difficult to locate, we have listed some relevant medical sites under Leading Cancer Links. We are always on the lookout for more so check our site often.

source:
National Cancer Institute, National Institute of Occupational Safety and Health, "Mesothelioma" edited by Bruce W.S. Robinson and A. Philippe Chahinian.

Diseases of the mesothelium

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* Mesothelioma: (cancer of the mesothelium) is a disease in which cells of the mesothelium become abnormal and divide without control or order. They can invade and damage nearby tissues and organs. Cancer cells can also metastasize (spread) from their original site to other parts of the body. Most cases of mesothelioma begin in the pleura or peritoneum. More than 90% of mesothelioma cases are linked to asbestos exposure.

* Intra-abdominal adhesions: Normally, the mesothelium secretes plasminogen, which removes fibrin deposits. During surgical procedures, the mesothelium may be damaged. Its fibrinolytic capacity becomes insufficient and fibrin accumulates, causing fibrous adhesions between opposing surfaces. These adhesions cause intestinal obstruction and female infertility if it occurs in the abdomen, and may impair cardiac and lung function in the thorax.

* Ultrafiltration failure: The peritoneal mesothelium is implicated in the long-term development of ultrafiltration failure in peritoneal dialysis patients. The presence of supra-physiological glucose concentrations, acidity, and glucose degradation products in peritoneal dialysis fluids contribute to the fibrosis of the peritoneal mesothelium, either by epithelial-mesenchymal transition or increased proliferation of existing fibroblasts. A fibrosed peritoneum results in the increased passage of solutes across the peritoneum and ultrafiltration failure.

source :
Histology at KUMC
wikipedia.org/wiki/Mesothelium

What is the mesothelium ?

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The mesothelium is a membrane that forms the lining of several body cavities: the pleura (thoracal cavity), peritoneum (abdominal cavity including the mesentery) and pericardium (heart sac). Mesothelial tissue also surrounds the male internal reproductive organs (the tunica vaginalis testis) and covers the internal reproductive organs of women (the tunica serosa uteri). Mesothelium that covers the internal organs is called visceral mesothelium, while the layer that covers the body walls is called the parietal mesothelium.

Origin

Mesothelium derives from the embryonic mesoderm cell layer, that lines the coelom (body cavity) in the embryo. It develops into the layer of cells that covers and protects most of the internal organs of the body.

Structure

The mesothelium forms a monolayer of flattened squamous-like epithelial cells resting on a thin basement membrane supported by connective tissue. Cuboidal mesothelial cells may be found at areas of injury, the milky spots of the omentum, and the peritoneal side of the diaphragm overlaying the lymphatic lacunae. The luminal surface is covered with microvilli. The proteins and serosal fluid trapped by the microvilli provide a frictionless surface for internal organs to slide past one another.

Function

The mesothelium is composed of an extensive monolayer of specialized cells (mesothelial cells) that line the body's serous cavities and internal organs. The main purpose of these cells is to produce a lubricating fluid that is released between layers, providing a slippery, non-adhesive and protective surface to facilitate intracoelomic movement.

The mesothelium is also implicated in the transport and movement of fluid and particulate matter across the serosal cavities, leukocyte migration in response to inflammatory mediators, synthesis of pro-inflammatory cytokines, growth factors and extracellular matrix proteins to aid in serosal repair, and the release of factors to promote the disposition and clearance of fibrin (such as plasminogen). It is an antigen presenting cell. Furthermore, the secretion of glycosaminoglycans and lubricants may protect the body against infection and tumor dissemination.

sources
wikipedia.org/wiki/Mesothelium
Mutsaers SE. "Mesothelial cells: Their structure, function, and role in serosal repair."