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MESOTELIOMA

MESOTELIOMA. Malignant Mesothelioma. Pleural vs. peritoneal Pleural: breathlessness, pleural effusion, chest wall pain or incidentally Peritoneal: distention from ascites, abd. Pain. Causes. Asbestos Long thin fibers: amphiboles (blue): main Ca causer

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MESOTELIOMA

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  1. MESOTELIOMA

  2. Malignant Mesothelioma • Pleural vs. peritoneal • Pleural: breathlessness, pleural effusion, chest wall pain or incidentally • Peritoneal: distention from ascites, abd. Pain

  3. Causes • Asbestos • Long thin fibers: amphiboles (blue): main Ca causer • Feathery fibers: serpentine or chrysotile (white) • Simian virus 40 (SV40): also implicated cofactor (oncogenic virus)

  4. Diagnosis • Diagnosis is made on HISTOLOGY • Cytology: Only in epithelial histotype • A pathology panel is preferred • Clinical information can help

  5. Diagnosis • Cytology: + in >3/4 of cases • Stain + for calretinin, wilms tumor antigen 1 (WT1) determines if mesothelial cells. Ck 5/6 • (adenoCA does not) • Stain for BerEP4/TTF-1 IN ADENOCARCINOMA • Or via histopathology via Bx

  6. Diagnosis • Imaging: • CXR: can show effusion, pleural mass or plaques (not a precursor to cancer) • CT: effusions or mass (pleural based) • Can see thickening of intralobular septum • Can see uniform rind of tumor encasing lung • Can see local tumor mass • Can see invasion into chest wall ~20% usually from a procedure • MRI: good to see extent of tumor particularly when invading into local structures • PET: used to help differentiate benign from malignant pleural lesions and extra thoracic disease (helps with staging)

  7. How deep is your biopsy? Not Diagnostic Diagnostic

  8. MESOTELIOMA EPITELIODEO

  9. MESOTELIOMA MALIGNO FIBROSO

  10. Prognosis and Staging • Median survival: from time of diagnosis: 12 months (range 6-18m): for treated patients • survival: from time of diagnosis: 4-13 months: for untreated patients • CT/MRI/PET important in staging pt. • Also role for mediastinoscopy/laparoscopy for staging • Use modified TMN staging system • International Mesothelioma Interest Group • Poor prognosis: thrombocytosis, leukocytosis, low HgB, fever, age>65, poor performance status, male • Good prognosis: epithelial histo, stage 1, age <65, low perform score, no CP, symptoms present > 6 months before Dx

  11. Treatment • Surgery: most useful for palliation and should be combined with radiotherapy or chemotherapy • Chemo: Past response rate <20% • New advances: • Pemetrexed (inhibits dihydrofolate reductase and thymidylate synthase): overall survival increased 11 months • Pemetrexed + cisplatin: increased survival another 3m • Similar response with other combo chemo regimens with 3-6 m increase in addition to single agent • Gemcitabine: subjective improvement • Gleevec and Iressa (block PDGF/EGF): no response • Radiotherapy: palliative relief for pain • Trials with immune and gene therapy on going

  12. Peritoneal mesothelioma • Treatment usually includes surgical cytoreduction • Intraperitoneal chemo • For recurrent or unresectable disease: palliative chemo (pemetrexed and cisplatin)

  13. Palliative treatment • Recurrent pleural effusions: talc application or pleurodesis • Somatic, visceral (organ involvement) and neuropathic pain: • Opiods, nsaids, other

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