Treating Mesothelioma

Some early-stage mesotheliomas are potentially resectable, but there are exceptions. Even if the cancer is resectable, it can be very hard to remove all of it.

Whether a tumor is resectable is also based on the subtype. Surgery to remove the cancer is most likely to be helpful for epithelioid mesothelioma. It’s less likely to be useful for sarcomatoid or mixed (biphasic) tumors.

Other important factors include where it is in the body, how far it has grown into nearby tissues, and if a person is healthy enough to have surgery.

Treating resectable pleural mesothelioma

In general, options for resectable pleural mesothelioma include:

• Systemic (whole-body) treatment such as chemotherapy, targeted therapy, and/or immunotherapy, possibly along with radiation therapy
• Systemic treatment, followed by surgery and possibly radiation therapy
• Surgery, followed by systemic therapy and possibly radiation therapy
• Observation (watching the cancer closely and then treating as needed)

The most common surgery to try to remove pleural mesothelioma is a pleurectomy/decortication (P/D).

An extrapleural pneumonectomy (EPP) might also be an option. Although it’s a more complex and extensive operation that is more likely to cause complications, so not everyone can tolerate it.

The goal of surgery is to remove all visible cancer. But sometimes once the operation starts, it becomes clear that not all the cancer can be removed.

If this happens, the surgeon might switch to a less extensive operation aimed at limiting future symptoms, or even stop the surgery if it’s not likely to be helpful. Treatment would then be the same as for unresectable mesotheliomas (see below).

Other treatments might be helpful as well. For example, if you have symptoms because of fluid buildup in the chest, treatments such as thoracentesis or pleurodesis might be helpful. These are described below under Palliative treatments for mesothelioma.

Because these cancers can be hard to treat, taking part in a clinical trial that is testing newer treatments might be another option. These types of studies are usually done in large medical centers.

Treating resectable peritoneal mesothelioma

Some people with early-stage peritoneal mesothelioma might benefit from surgery to take out as much of the cancer as possible. This is known as debulking or cytoreductive surgery. It is usually combined with heated intraperitoneal chemotherapy (HIPEC), which is given during the operation.

Further treatment depends on the risk of the mesothelioma coming back after surgery:

• If the mesothelioma is at lower risk of returning, observation might be an option at this point. If the cancer returns, medicines such as chemotherapy, targeted therapy, and immunotherapy can be given.
• If the mesothelioma is at higher risk of returning, surgery is usually followed by systemic treatments such as chemotherapy, targeted therapy, and immunotherapy.

Other treatments might be helpful as well. For example, if you have symptoms because of fluid buildup in the abdomen (known as ascites), treatments such as paracentesis or pleurodesis might be helpful. These are described below under Palliative treatments for mesothelioma.

Because these cancers can be hard to treat, taking part in a clinical trial testing newer treatments might be another option. These types of studies are usually done in large medical centers.

Many mesotheliomas can’t be removed completely by surgery. This might be because of the extent or subtype of the cancer or because a person isn't healthy enough to have an operation.

Chemotherapy and immunotherapy are typically the main types of treatment for these cancers. Immunotherapy may often be used first, alone or in combination with chemotherapy. Additional treatments may include targeted therapy or a device that creates electric fields in the tumor.

These treatments might help you live longer, although it’s very unlikely that they will cure the cancer.

Because these cancers can be hard to treat, taking part in a clinical trial of a new treatment might be a good option.

Treatment aimed at relieving symptoms and making you more comfortable, called palliative or supportive care (described below), can often be helpful, regardless of what other treatments you’re getting.

It’s often hard to remove or destroy mesothelioma completely. It might progress (grow) while you’re getting treatment or it might recur (come back) after treatment.

If mesothelioma progresses or recurs, further treatment options depend on where the cancer is, what treatments you’ve already had, and your overall health and preferences.

Most often, your options will be a lot like those listed above for unresectable mesotheliomas. For example, chemotherapy, immunotherapy, or radiation therapy might be used to try to shrink or slow the growth of the cancer and to relieve any symptoms.

Because recurrent mesothelioma is hard to treat, clinical trials of new types of treatment might be a good option. For more information, see Understanding Recurrence.

If pleural mesothelioma is causing fluid to build up in the body, it can often cause trouble breathing and other problems. Sometimes procedures can be used to remove the fluid or help keep it from coming back.

Thoracentesis, paracentesis, and pericardiocentesis are procedures that can be used to take out fluid that has built up and is causing symptoms such as trouble breathing. A long, hollow needle is put through the skin to remove the fluid.

These procedures can be used to test for cancer, but in this case, they are used to remove fluid. The fluid often builds up again, so these procedures might need to be repeated.

This procedure might be used for pleural mesotheliomas to try to keep fluid from building up in the chest.

A small cut is made in the skin of the chest wall, and a hollow tube is put into the chest so that the fluid can drain out. Then, a medicine is put into the chest tube. Examples include talc mixed in a fluid (talc slurry), the antibiotic doxycycline, or the chemotherapy drug bleomycin.

This irritates the linings of the lung (visceral pleura) and chest wall (parietal pleura) so that they stick together, sealing the space and preventing further fluid build-up.

The tube is generally left in for a day or 2 to drain any new fluid.

Pleurodesis can also be done during a thoracoscopy.

This is another approach sometimes used to control fluid build-up.

One end of the catheter (a thin, flexible tube) is put through a small cut in the skin and the other end is left outside the body. It is placed in the chest for pleural mesothelioma and in the abdomen (belly) for peritoneal mesothelioma.

 This is done in a doctor’s office or hospital. Once in place, the catheter can be attached to a special bottle or another device to drain fluid out on a regular basis.

Because recurrent mesothelioma is hard to treat, clinical trials of new types of treatment might be a good option. For more information, see Understanding Recurrence.

A shunt is a is a long, thin, flexible tube with a small pump in the middle that allows fluid to move from one part of the body to another.

For example, a pleuro-peritoneal shunt lets excess fluid in the chest drain into the abdomen. There, it's more likely to be absorbed by the body. A shunt might be used if pleurodesis or other techniques don't work, but it’s not used often.

In the operating room, the doctor puts one end of the shunt into the chest space and the other end into the abdomen. The pump part stays just under the skin over the ribs. Once the shunt is in place, the person pushes down on the pump several times to move the fluid from the chest to the abdomen.

Pain management is an important aspect of care for mesothelioma. Some minor operations and types of radiation therapy can be used to help relieve pain. Doctors can also prescribe strong pain-relieving drugs, if needed.

Some people with cancer are worried about taking opioid medicines, such as morphine, for fear of being sleepy all the time or becoming addicted to them. But many people get very good pain relief from these medicines without serious side effects.

It’s very important to let your cancer care team know if you're having pain so that it can be treated.