Elsevier

Seminars in Oncology

Volume 29, Issue 1, February 2002, Pages 41-50
Seminars in Oncology

Multimodality treatment of diffuse malignant pleural mesothelioma*

https://doi.org/10.1053/sonc.2002.30230Get rights and content

Abstract

Diffuse malignant pleural mesothelioma (DMPM) is a challenging disease in all of its aspects, from presentation and diagnosis to staging and treatment. Single-modality therapy was the initial approach to this disease. It generally has not been effective in changing the natural history of DMPM. As a result, multimodality regimens involving surgery with radiation, chemotherapy, or immunotherapy delivered regionally or systemically have been evaluated. Randomized controlled studies comparing various strategies are lacking and, thus, the debate continues regarding the effectiveness of different treatment approaches. Semin Oncol 29:41-50. Copyright © 2002 by W.B. Saunders Company.

Section snippets

Clinical presentation

The typical DMPM patient who presents for surgical evaluation is a male over the age of 55 (3:1 male-to-female ratio) with unilateral disease (95%). DMPM tends to be right-sided (60%).3 Patients usually report symptoms related to the presence of a pleural effusion, such as dyspnea, cough, chest pain that may be nonpleuritic in nature, and occasionally fever, night sweats, fatigue, and weight loss.3 Unrelenting local spread with invasion into the chest wall, the lung and its fissures, the

Radiation therapy

Unresected diffuse malignant pleural mesothelioma is difficult to treat with radiation alone. Unlike other tumors, mesothelioma is a diffuse process, and a much larger radiation field is required compared to other thoracic malignancies. Numerous vital structures limit the radiation dose that can be safely delivered (lung, 20 Gy; liver, 30 Gy; spinal cord, 45 Gy; heart, 45 Gy; and esophagus, 45 to 50 Gy).18 The Joint Center for Radiation Therapy in Boston conducted a review of mesothelioma

Multimodality treatment

Several multimodality approaches have been evaluated for the treatment of DMPM due to the failure of single modality therapy to affect survival. Cytoreductive surgery (P/D or EPP) has been incorporated with intrapleural or external-beam radiotherapy, intrapleural and/or systemic immunotherapy, and chemotherapy. Efforts have mainly focused on improving local control of this disease.

Conclusions

DMPM remains a difficult disease to treat. Like any other malignancy, early diagnosis is essential. Treatment must be tailored according to stage and histologic subtype. Overall, there is a trend in these studies for improved survival in patients with early stage disease. Patients with advanced disease have not enjoyed this benefit with multimodality regimens. The Brigham/DFCI approach of EPP and adjuvant chemoradiation with a median survival of 51 months is the longest survival of any reported

Acknowledgements

The authors thank Mary S. Visciano for editorial assistance

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    *

    Address reprint requests to David J. Sugarbaker, MD, Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston MA 02115.

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