Pleural Cancer (Mesothelioma) Treatment

Mesothelioma is a rare but aggressive type of cancer that originates from mesothelial tissues such as the pleura (lung lining), peritoneum (abdominal lining), or pericardium (heart lining). The most common cause is long-term asbestos exposure, and diagnosis is often made in advanced stages.

The question of what the symptoms of mesothelioma are is important for early diagnosis. In pleural mesothelioma, symptoms such as chest pain, shortness of breath, and persistent cough are prominent. The peritoneal type manifests with abdominal pain and bloating, while symptoms usually develop slowly and are not specific.

The question of how mesothelioma is diagnosed is critical for proper treatment planning. In the process that begins with imaging methods, CT and PET scans are used; the definitive diagnosis is made by biopsy. Immunohistochemical examinations guide the determination of the tumor type.

Treatment methods for mesothelioma include a combination of surgery, chemotherapy, and radiotherapy. The treatment approach is determined according to the stage of the disease and the patient’s general condition. While surgical options are at the forefront in early stages, systemic treatments are preferred in advanced stages.

What Is Lung Lining Cancer (Mesothelioma)?

Lung lining cancer (mesothelioma) is a rare and aggressive type of cancer originating from the pleural membrane surrounding the lungs. The most important risk factor is asbestos exposure. The disease usually appears after a long latent period and may present with symptoms such as shortness of breath, chest pain, and pleural fluid accumulation. Although early diagnosis is difficult, treatment options may include surgery, chemotherapy, and radiotherapy. A multidisciplinary approach is important.

Why Is Mesothelioma So Common in Turkey?

When we look globally, mesothelioma is actually a very rare disease, seen in about one or two people per million. However, unfortunately, our country presents a very concerning picture far outside global statistics in this regard. In Turkey, approximately 500 new patients are diagnosed each year. These figures prove that Turkey is an “endemic” region for mesothelioma, meaning a region where the disease is frequently seen as a local occurrence. This situation causes a Turkish thoracic surgeon to encounter far more cases during their professional life compared to international colleagues and to gain deeper experience on this subject.

So why is it so common here? The answer cannot be explained only by industrial asbestos use, such as shipyard work or the construction sector. Turkey has its own unique reality that we call “environmental exposure.” Especially in the Central Anatolia Region, in some villages around Nevşehir and Ürgüp, a material known as “white soil” or “ak soil” was used for many years in plastering and whitewashing houses. Unfortunately, this soil contains a mineral called “Erionite.” In terms of carcinogenic effect, erionite is an even stronger and more dangerous mineral than asbestos. Citizens living in these villages have inhaled these dusts since infancy.

Scientific studies conducted in these villages reveal the seriousness of the situation. In regions with erionite exposure, the risk of disease has been found to be hundreds of times higher than the global average, and even thousands of times higher in women. For this reason, when evaluating a patient who comes to our clinic with shortness of breath, we do not only ask about their occupation; we also question in detail which village they were born in, whether white soil was used on the walls of their home, and where their childhood was spent. Because the duration of exposure to mineral fibers and the time elapsed after first contact are the most important factors determining the magnitude of the risk.

Risky regions and factors are as follows:

• Nevşehir region
• Ürgüp surroundings
• Tuzköy
• Karain
• Sarıhıdır villages
• Use of white soil

What Are the Symptoms of the Disease and How Do Patients Present to Us?

Mesothelioma begins insidiously but gives clear signals as it progresses. Our patients most often present with complaints of progressive shortness of breath caused by fluid accumulation between the pleural membranes of the lungs, medically known as pleural effusion. Initially, this shortness of breath is felt only while walking, climbing a slope, or going up stairs, but over time it progresses so much that the patient has difficulty breathing even at rest or while sitting. This fluid accumulation prevents the lungs from expanding and contracting comfortably and creates pressure in the chest cavity.

In addition, a dull pain felt in the chest wall, which cannot be precisely localized but disturbs the patient, is another common symptom. As the disease progresses and the tumor tissue begins to exceed the lung lining and press on the chest wall, ribs, or nerves, this pain may intensify and become sharper. Sometimes a persistent and dry cough may also accompany the condition. If the disease has progressed to more advanced stages, symptoms such as swelling of the face and neck and difficulty swallowing may develop due to the tumor pressing on large vessels in the chest cavity.

Common symptoms are as follows:

• Progressive shortness of breath
• Chest pain
• Persistent cough
• Fatigue
• Weight loss
• Difficulty swallowing
• Swelling in the face

Which Technological Methods Are Used When Making a Diagnosis?

Before starting treatment of the disease, we must have definitive evidence in our hands. Although a simple chest X-ray may be sufficient to raise suspicion, it is never enough for detailed surgical planning. In current medical guidelines and in our own practice, we accept integrated PET-CT imaging that combines Computed Tomography (CT) with Positron Emission Tomography (PET) technology as the gold standard.

PET-CT shows us two things at the same time: First, the anatomical location of the tumor, how close it is to which rib and which vessel. Second, the metabolic activity of the tissue; in other words, it gives us information about how alive and aggressive the tumor is. This imaging allows us to understand whether the tumor is limited to the chest cavity or has spread to distant organs, which is the most critical stage in deciding on surgery. However, no matter how advanced imaging becomes, the definitive diagnosis is made with a tissue sample, that is, a biopsy.

The diagnostic tools we use are as follows:

• Chest X-ray
• Computed Tomography
• PET-CT imaging
• Closed biopsy
• Pathological examination

How Is Surgical Candidate Selection Made and What Are the Criteria?

This question is perhaps the most challenging part of mesothelioma management. Because technically being able to remove a tumor does not mean that surgery is the right decision for the patient. Mesothelioma surgery, especially radical surgeries, is a major trauma for the body and not every patient can tolerate this burden. Before deciding on curative surgery aimed at complete recovery, we subject our patient to a very strict selection process.

The first rule is that the disease must not have spread to other organs. The second rule, which is just as important, is the patient’s physiological reserve. Heart health, in particular, is a non-negotiable criterion here. In the echocardiography of our patients, the pumping power of the heart must be above a certain level. In addition, the absence of severe insufficiency in the right heart valve is another condition we look for. These criteria are not arbitrary; after surgery, especially when the lung lining is stripped or partially removed, they are vital for the heart to adapt to the new circulation system and to prevent sudden heart failure.

The evaluated criteria are as follows:

• Spread of the tumor
• Cardiac pumping power
• Right heart functions
• Nutritional status
• Presence of diabetes
• General performance

What Are the Surgical Methods: Should the Lung Be Preserved?

From the perspective of thoracic surgery, there are two main philosophies and two different technical approaches in mesothelioma surgery. Our main goal is always to remove all visible parts of the tumor. However, while doing this, keeping the patient alive and preserving quality of life are equally important.

The first and older method is called Extrapleural Pneumonectomy (EPP). This is an extremely radical procedure. The affected lung, the surrounding lining, a part of the diaphragm, and a part of the pericardium are removed as a single block. In other words, one lung of the patient is completely removed. In the past, this method was seen as the only way to completely eliminate the tumor from the body. However, the risk of this surgery is high and it is open to serious complications.

The second approach, which we prefer more today, is the Pleurectomy/Decortication (P/D) procedure. Here the philosophy is “lung-preserving” surgery. The lung itself is left in place, and only the diseased membranes and tumor tissues on it are peeled off and cleaned. You can think of it like peeling an orange; you remove the peel but the fruit remains. Clinical data show that lung-preserving surgery has very important advantages.

The techniques applied in surgery are as follows:

• Extrapleural Pneumonectomy
• Pleurectomy
• Decortication
• Diaphragm resection
• Pericardial resection

At Which Stage Is the Closed Surgical Method (VATS) Used?

With the development of technology, our ability in thoracic surgery to perform procedures through small openings with the help of a camera without making large incisions has increased. In mesothelioma, Videothoracoscopy, that is the VATS method, has a very critical role. First of all, during the diagnostic stage, it allows us to take a biopsy and drain the fluid without opening the patient’s chest.

However, its most strategic use is “surgical staging.” Before planning a major surgery for a patient, we enter the chest cavity with VATS and inspect it. Are there nodules on the lung or in deep tissues? How far has the tumor spread? If there is no spread to the lung tissue itself, we decide that the patient is suitable for lung-preserving surgery. In other words, VATS is like a guiding light that helps us determine which surgical technique to choose. In addition, it offers invaluable comfort for the patient such as less pain, shorter hospital stay, and faster return to daily life.

The advantages of the VATS method are as follows:

• Less pain
• Small incisions
• Fast recovery
• Short hospital stay
• Early discharge
• Cosmetic superiority

Why Is a Multimodal Treatment Approach Necessary?

The most important message we give our patients in the treatment of mesothelioma is this: surgery is only one front of this battle. Surgery alone is never sufficient to completely eliminate the disease because this tumor has a high tendency to leave microscopic cells behind. For this reason, we apply the triple treatment concept we call “Trimodality.” This concept consists of the combination of surgery, chemotherapy, and radiotherapy.

The success of these three components depends on their complementarity. The surgeon removes the tumor at a visible level. The oncologist targets the remaining microscopic cells with chemotherapy. The radiation oncologist applies radiation therapy to prevent local recurrences. This multidisciplinary approach is the most effective strategy that prolongs patient survival.

The components of multimodal treatment are as follows:

• Maximum surgical clearance
• Systemic chemotherapy
• Local radiotherapy
• Supportive treatments
• Nutritional support

Which Drugs Are Preferred in Chemotherapy Treatment?

Chemotherapy is an indispensable part of mesothelioma treatment. It can be applied before surgery to shrink the tumor or after surgery to eliminate remaining microscopic cells. While the effect of drugs used alone was limited in the past, today we obtain much more successful results with combination treatments.

In systemic treatment, we generally use a combination of platinum group drugs with Pemetrexed. Our data in Turkey show that this combination can provide more favorable results compared to other protocols and that complete response can be obtained in some cases. Especially if we have performed lung-preserving surgery, the patient can tolerate these intensive drug treatments with a stronger physical condition, which increases our overall success rate. The patient’s general condition must be good in order to complete these treatments.

The main drug groups used are as follows:

• Cisplatin
• Carboplatin
• Pemetrexed
• Gemcitabine
• Supportive medications

What Is the Role and Importance of Radiotherapy in Treatment?

Radiation therapy, that is radiotherapy, has two main areas of use in this disease: protection and pain relief. Mesothelioma cells tend to implant in areas where surgical procedures are performed, such as incision sites, drainage points, or needle entry sites, and grow again there. This is a serious condition that increases the risk of recurrence after surgery.

For this reason, after performing a surgical procedure, for example after inserting and removing a chest tube, we apply “Prophylactic Radiotherapy” to those entry sites. Radiation given at specific doses prevents the tumor from regrowing in those small openings. This is an indispensable part of surgical safety. The other area of use is palliative treatment. In advanced stages of the disease, severe pain in the chest wall or pain due to bone metastases may occur. In such cases, radiotherapy is the most effective tool for relieving pain and ensuring patient comfort.

The purposes of radiotherapy are as follows:

• Protection of drainage sites
• Protection of incision sites
• Prevention of local recurrence
• Pain control
• Treatment of metastases

How Should the Approach Be in Advanced-Stage Patients?

Unfortunately, not every patient may reach us at an early stage, or their medical condition may not be suitable to tolerate a major operation. However, this does not mean that nothing can be done for these patients. An important part of thoracic surgery practice consists of interventions aimed at improving the quality of life of patients in this situation.

The most common procedure we perform is managing the fluid that accumulates in the lung lining and causes the patient to feel as if they are suffocating. We drain this fluid and perform a procedure to adhere the pleural layers to prevent it from accumulating again. This procedure significantly reduces the patient’s shortness of breath. Our goal is to ensure that the patient spends the remainder of their life pain-free, without shortness of breath, and with good quality together with their family. Palliative care does not mean abandoning the patient; on the contrary, it focuses on their comfort.

The goals of palliative treatment are as follows:

• Fluid drainage
• Pleurodesis procedure
• Relief of shortness of breath
• Pain relief
• Improvement of quality of life
• Nutritional support

Frequently Asked Questions