|
mesothelioma cancer
Mesothelioma is a form of cancer that is almost
always caused by previous exposure to asbestos.[1] In this disease,
malignant cells develop in the mesothelium, a protective lining that
covers most of the body's internal organs. Its most common site is the
pleura (outer lining of the lungs and chest cavity), but it may also
occur in the peritoneum (the lining of the abdominal cavity) or the
pericardium (a sac that surrounds the heart).
Most people who develop mesothelioma have worked on jobs where they
inhaled asbestos particles, or have been exposed to asbestos dust and
fibre in other ways, such as by washing the clothes of a family member
who worked with asbestos, or by home renovation using asbestos cement
products. There is no association between mesothelioma and smoking.[2]
Signs and symptoms
Symptoms of mesothelioma may not appear until 20 to 50 years after
exposure to asbestos. Shortness of breath, cough, and pain in the
chest due to an accumulation of fluid in the pleural space are often
symptoms of pleural mesothelioma.
Symptoms of peritoneal mesothelioma include weight loss and cachexia,
abdominal swelling and pain due to ascites (a buildup of fluid in the
abdominal cavity). Other symptoms of peritoneal mesothelioma may
include bowel obstruction, blood clotting abnormalities, anemia, and
fever. If the cancer has spread beyond the mesothelium to other parts
of the body, symptoms may include pain, trouble swallowing, or
swelling of the neck or face.
These symptoms may be caused by mesothelioma or by other, less serious
conditions.
Mesothelioma that affects the pleura can cause these signs and
symptoms:
chest wall pain
pleural effusion, or fluid surrounding the lung
shortness of breath
wheezing, hoarseness, or cough
In severe cases, the person may have many tumor masses. The individual
may develop a pneumothorax, or collapse of the lung. The disease may
metastasize, or spread, to other parts of the body.
Tumors that affect the abdominal cavity often do not cause symptoms
until they are at a late stage. Symptoms include:
abdominal pain
ascites, or an abnormal buildup of fluid in the abdomen
a mass in the abdomen
problems with bowel function
weight loss
In severe cases of the disease, the following signs and symptoms may
be present:
blood clots in the veins, which may cause thrombophlebitis
disseminated intravascular coagulation, a disorder causing severe
bleeding in many body organs
jaundice, or yellowing of the eyes and skin
low blood sugar level
pleural effusion
pulmonary emboli, or blood clots in the arteries of the lungs
severe ascites
A mesothelioma does not usually spread to the bone, brain, or adrenal
glands. Pleural tumors are usually found only on one side of the
lungs.
Diagnosis
Diagnosing mesothelioma is often difficult, because the
symptoms are similar to those of a number of other conditions.
Diagnosis begins with a review of the patient's medical history. A
history of exposure to asbestos may increase clinical suspicion for
mesothelioma. A physical examination is performed, followed by chest
X-ray and often lung function tests. The X-ray may reveal pleural
thickening commonly seen after asbestos exposure and increases
suspicion of mesothelioma. A CT (or CAT) scan or an MRI is usually
performed. If a large amount of fluid is present, abnormal cells may
be detected by cytology if this fluid is aspirated with a syringe. For
pleural fluid this is done by a pleural tap or chest drain, in ascites
with an paracentesis or ascitic drain and in a pericardial effusion
with pericardiocentesis. While absence of malignant cells on cytology
does not completely exclude mesothelioma, it makes it much more
unlikely, especially if an alternative diagnosis can be made (e.g.
tuberculosis, heart failure).
If cytology is positive or a plaque is regarded as suspicious, a
biopsy is needed to confirm a diagnosis of mesothelioma. A doctor
removes a sample of tissue for examination under a microscope by a
pathologist. A biopsy may be done in different ways, depending on
where the abnormal area is located. If the cancer is in the chest, the
doctor may perform a thoracoscopy. In this procedure, the doctor makes
a small cut through the chest wall and puts a thin, lighted tube
called a thoracoscope into the chest between two ribs. Thoracoscopy
allows the doctor to look inside the chest and obtain tissue samples.
If the cancer is in the abdomen, the doctor may perform a laparoscopy.
To obtain tissue for examination, the doctor makes a small opening in
the abdomen and inserts a special instrument into the abdominal
cavity. If these procedures do not yield enough tissue, more extensive
diagnostic surgery may be necessary.
Typical immunohistochemistry results Positive Negative
EMA (epithelial membrane antigen) in a membranous distribution CEA (carcinoembryonic
antigen)
WT1 (Wilms' tumour 1) B72.3
Calretinin MOC-3 1
Mesothelin-1 CD15
Cytokeratin 5/6 Ber-EP4
HBME-1 (human mesothelial cell 1) TTF-1 (thyroid transcription
factor-1)
Screening
There is no universally agreed protocol for screening
people who have been exposed to asbestos. However some research
indicates that the serum osteopontin level might be useful in
screening asbestos-exposed people for mesothelioma. The level of
soluble mesothelin-related protein is elevated in the serum of about
75% of patients at diagnosis and it has been suggested that it may be
useful for screening[3].
Staging
Once the diagnosis is confirmed, the doctor may need to
assess the stage to help plan treatment.
Mesothelioma is described as localized if the cancer is found only on
the membrane surface where it originated. It is classified as advanced
if it has spread beyond the original membrane surface to other parts
of the body, such as the lymph nodes, lungs, chest wall, or abdominal
organs.
Pathophysiology
The mesothelium consists of a single layer of flattened to
cuboidal cells forming the epithelial lining of the serous cavities of
the body including the peritoneal, pericardial and pleural cavities.
Deposition of asbestos fibres in the parenchyma of the lung may result
in the penetration of the visceral pleura from where the fibre can
then be carried to the pleural surface, thus leading to the
development of malignant mesothelial plaques. The processes leading to
the development of peritoneal mesothelioma remain unresolved, although
it has been proposed that asbestos fibres from the lung are
transported to the abdomen and associated organs via the lymphatic
system. Additionally, asbestos fibres may be deposited in the gut
after ingestion of sputum contaminated with asbestos fibres.
Pleural contamination with asbestos or other mineral fibres has been
shown to cause cancer. Long thin asbestos fibers (blue asbestos,
amphibole fibers) are more potent carcinogens than "feathery fibers" (chrysotile
or white asbestos fibers)[4]. However, there is now evidence that
smaller particles may be more dangerous than the larger fibers.[1][2]
They remain suspended in the air where they can be inhaled, and may
penetrate more easily and deeper into the lungs. "We probably will
find out a lot more about the health aspects of asbestos from [the
World Trade Center attack], unfortunately," said Dr. Alan Fein, chief
of pulmonary and critical-care medicine at North Shore-Long Island
Jewish Health System. Dr. Fein has treated several patients for "World
Trade Center syndrome" or respiratory ailments from brief exposures of
only a day or two near the collapsed buildings.[3]
Mesothelioma development in rats has been demonstrated following
intra-pleural inoculation of phosphorylated chrysotile fibres. It has
been suggested that in humans, transport of fibres to the pleura is
critical to the pathogenesis of mesothelioma. This is supported by the
observed recruitment of significant numbers of macrophages and other
cells of the immune system to localised lesions of accumulated
asbestos fibres in the pleural and peritoneal cavities of rats. These
lesions continued to attract and accumulate macrophages as the disease
progressed, and cellular changes within the lesion culminated in a
morphologically malignant tumour.
Experimental evidence suggests that asbestos acts as a complete
carcinogen with the development of mesothelioma occurring in
sequential stages of initiation and promotion. The molecular
mechanisms underlying the malignant transformation of normal
mesothelial cells by asbestos fibres remain unclear despite the
demonstration of its oncogenic capabilities. However, complete in
vitro transformation of normal human mesothelial cells to malignant
phenotype following exposure to asbestos fibres has not yet been
achieved. In general, asbestos fibres are thought to act through
direct physical interactions with the cells of the mesothelium in
conjunction with indirect effects following interaction with
inflammatory cells such as macrophages.
Analysis of the interactions between asbestos fibres and DNA has shown
that phagocytosed fibres are able to make contact with chromosomes,
often adhering to the chromatin fibres or becoming entangled within
the chromosome. This contact between the asbestos fibre and the
chromosomes or structural proteins of the spindle apparatus can induce
complex abnormalities. The most common abnormality is monosomy of
chromosome 22. Other frequent abnormalities include structural
rearrangement of 1p, 3p, 9p and 6q chromosome arms.
Common gene abnormalities in mesothelioma cell lines include deletion
of the tumor suppressor genes:
Neurofibromatosis type 2 at 22q12
P16INK4A
P14ARF
Asbestos has also been shown to mediate the entry of foreign DNA into
target cells. Incorporation of this foreign DNA may lead to mutations
and oncogenesis by several possible mechanisms:
Inactivation of tumor suppressor genes
Activation of oncogenes
Activation of proto-oncogenes due to incorporation of foreign DNA
containing a promoter region
Activation of DNA repair enzymes, which may be prone to error
Activation of telomerase
Prevention of apoptosis
Asbestos fibres have been shown to alter the function and secretory
properties of macrophages, ultimately creating conditions which favour
the development of mesothelioma. Following asbestos phagocytosis,
macrophages generate increased amounts of hydroxyl radicals, which are
normal by-products of cellular anaerobic metabolism. However, these
free radicals are also known clastogenic and membrane-active agents
thought to promote asbestos carcinogenicity. These oxidants can
participate in the oncogenic process by directly and indirectly
interacting with DNA, modifying membrane-associated cellular events,
including oncogene activation and perturbation of cellular antioxidant
defences.
Asbestos also may possess immunosuppressive properties. For example,
chrysotile fibres have been shown to depress the in vitro
proliferation of phytohemagglutinin-stimulated peripheral blood
lymphocytes, suppress natural killer cell lysis and significantly
reduce lymphokine-activated killer (LAK) cell viability and recovery.
Furthermore, genetic alterations in asbestos-activated macrophages may
result in the release of potent mesothelial cell mitogens such as
platelet-derived growth factor (PDGF) and transforming growth factor-β
(TGF-β) which in turn, may induce the chronic stimulation and
proliferation of mesothelial cells after injury by asbestos fibres.
Epidemiology
Incidence
Although reported incidence rates have increased in the
past 20 years, mesothelioma is still a relatively rare cancer. The
incidence is approximately one per 1,000,000. For comparison,
populations with high levels of smoking can have a lung cancer
incidence of over 1,000 per 1,000,000. Incidence of malignant
mesothelioma currently ranges from about 7 to 40 per 1,000,000 in
industrialized Western nations, depending on the amount of asbestos
exposure of the populations during the past several decades[5]. It has
been estimated that incidence may have peaked at 15 per 1,000,000 in
the United States in 2004. Incidence is expected to continue
increasing in other parts of the world. Mesothelioma occurs more often
in men than in women and risk increases with age, but this disease can
appear in either men or women at any age. Approximately one fifth to
one third of all mesotheliomas are peritoneal.
Between 1940 and 1979, approximately 27.5 million people were
occupationally exposed to asbestos in the United States.[4] Between
1973 and 1984, there has been a three-fold increase in the diagnosis
of pleural mesothelioma in caucasian males. From 1980 to the late
1990s, the rate of deaths from mesothelioma increased from 2,000 to
3,000 a year. in the late 1990se in annual deaths from mesotheilioma.
[5], with men four times more likely to acquire it than women. These
rates may not be accurate, since it is possible that many cases of
mesothelioma are misdiagnosed as adenocarcinoma of the lung, which is
difficult to differentiate from mesothelioma.
Risk factors
Working with asbestos is the major risk factor for
mesothelioma. A history of asbestos exposure exists in almost all
cases. However, mesothelioma has been reported in some individuals
without any known exposure to asbestos. In rare cases, mesothelioma
has also been associated with irradiation, intrapleural thorium
dioxide (Thorotrast), and inhalation of other fibrous silicates, such
as erionite.
Asbestos is the name of a group of minerals that occur naturally as
masses of strong, flexible fibers that can be separated into thin
threads and woven. Asbestos has been widely used in many industrial
products, including cement, brake linings, roof shingles, flooring
products, textiles, and insulation. If tiny asbestos particles float
in the air, especially during the manufacturing process, they may be
inhaled or swallowed, and can cause serious health problems. In
addition to mesothelioma, exposure to asbestos increases the risk of
lung cancer, asbestosis (a noncancerous, chronic lung ailment), and
other cancers, such as those of the larynx and kidney.
The combination of smoking and asbestos exposure significantly
increases a person's risk of developing cancer of the airways (lung
cancer, bronchial carcinoma). The Kent brand of cigarettes used
asbestos in its filters for the first few years of production in the
1950s and some cases of mesothelioma have resulted. Smoking current
cigarettes does not appear to increase the risk of mesothelioma.
Some studies suggest that simian virus 40 (SV40) may act as a cofactor
in the development of mesothelioma[6].
Exposure
Asbestos has been mined and used commercially since the
late 1800s. Its use greatly increased during World War II. Since the
early 1940s, millions of American workers have been exposed to
asbestos dust. Initially, the risks associated with asbestos exposure
were not publicly known. However, an increased risk of developing
mesothelioma was later found among shipyard workers, people who work
in asbestos mines and mills, producers of asbestos products, workers
in the heating and construction industries, and other tradespeople.
Today, the U.S. Occupational Safety and Health Administration (OSHA)
sets limits for acceptable levels of asbestos exposure in the
workplace, and created guidelines for engineering controls and
respirators, protective clothing, exposure monitoring, hygiene
facilities and practices, warning signs, labeling, recordkeeping, and
medical exams. By contrast, the British Government's Health and Safety
Executive (HSE) states formally that any threshold for mesothelioma
must be at a very low level and it is widely agreed that if any such
threshold does exist at all, then it cannot currently be quantified.
For practical purposes, therefore, HSE does not assume that any such
threshold exists. People who work with asbestos wear personal
protective equipment to lower their risk of exposure.
Exposure to asbestos fibres has been recognised as an occupational
health hazard since the early 1900s. Several epidemiological studies
have associated exposure to asbestos with the development of lesions
such as asbestos bodies in the sputum, pleural plaques, diffuse
pleural thickening, asbestosis, carcinoma of the lung and larynx,
gastrointestinal tumours, and diffuse mesothelioma of the pleura and
peritoneum.
The documented presence of asbestos fibres in water supplies and food
products has fostered concerns about the possible impact of long-term
and, as yet, unknown exposure of the general population to these
fibres. Although many authorities consider brief or transient exposure
to asbestos fibres as inconsequential and an unlikely risk factor,
some epidemiologists claim that there is no risk threshold. Cases of
mesothelioma have been found in people whose only exposure was
breathing the air through ventilation systems. Other cases had very
minimal (3 months or less) direct exposure.
Commercial asbestos mining at Wittenoom, Western Australia, occurred
between 1945 and 1966. A cohort study of miners employed at the mine
reported that while no deaths occurred within the first 10 years after
crocidolite exposure, 85 deaths attributable to mesothelioma had
occurred by 1985. By 1994, 539 reported deaths due to mesothelioma had
been reported in Western Australia.
Family members and others living with asbestos workers have an
increased risk of developing mesothelioma, and possibly other asbestos
related diseases. This risk may be the result of exposure to asbestos
dust brought home on the clothing and hair of asbestos workers. To
reduce the chance of exposing family members to asbestos fibres,
asbestos workers are usually required to shower and change their
clothing before leaving the workplace.
Treatment
Treatment of MM using conventional therapies has not proved
successful and patients have a median survival time of 6 - 12 months
after presentation. The clinical behaviour of the malignancy is
affected by several factors including the continuous mesothelial
surface of the pleural cavity which favours local metastasis via
exfoliated cells, invasion to underlying tissue and other organs
within the pleural cavity, and the extremely long latency period
between asbestos exposure and development of the disease.
Surgery
Surgery, either by itself or used in combination with pre-
and post-operative adjuvant therapies has proved disappointing with a
5 year survival rate of less than 10%. A pleurectomy/decortication is
the most common surgery, in which the lining of the chest is removed.
Less common is an extrapleural pneumonectomy (EPP), in which the lung,
lining of the inside of the chest, the hemi-diaphragm and the
pericardium are removed. It is not possible to remove the entire
mesothelium without killing the patient.
Radiation
Although the tumor is highly resistant to radiotherapy,
these regimens are sometimes used to relieve symptoms arising from
tumor growth, such as obstruction of a major blood vessel.
Radiotherapy is commonly applied to the sites of chest drain
insertion, in order to prevent growth of the tumor along the track in
the chest wall.
Chemotherapy
In February 2004, the Food and Drug Administration approved
pemetrexed (brand name Alimta) for treatment of malignant pleural
mesothelioma. Pemetrexed is given in combination with cisplatin. Folic
acid is also used to reduce the side-effects of pemetrexed.
Immunotherapy
Treatment regimens involving immunotherapy have yielded
variable results. For example, intrapleural inoculation of Bacillus
Calmette-Guérin (BCG) in an attempt to boost the immune response, was
found to be of no benefit to the patient (while it may benefit
patients with bladder cancer). Mesothelioma cells proved susceptible
to in vitro lysis by LAK cells following activation by interleukin-2
(IL-2), but patients undergoing this particular therapy experienced
major side effects. Indeed, this trial was suspended in view of the
unacceptably high levels of IL-2 toxicity and the severity of side
effects such as fever and cachexia. Nonetheless, other trials
involving interferon alpha have proved more encouraging with 20% of
patients experiencing a greater than 50% reduction in tumor mass
combined with minimal side effects.
Heated Intraoperative Intraperitoneal
Chemotherapy
A procedure known as heated intraoperative intraperitoneal
chemotherapy was developed by Paul Sugarbaker at the Washington Cancer
Institute[7]. The surgeon removes as much of the tumor as possible
followed by the direct administration of a chemotherapy agent, heated
to between 40 and 48°C, in the abdomen. The fluid is perfused for 60
to 120 minutes and then drained.
This technique permits the administration of high concentrations of
selected drugs into the abdominal and pelvic surfaces. Heating the
chemotherapy treatment increases the penetration of the drugs into
tissues. Also, heating itself damages the malignant cells more than
the normal cells.
Prevention & Expectations
What can be done to prevent the disease? Since the 1970s,
the Environmental Protection Agency and the Occupational Safety and
Health Administration have regulated the asbestos industry in the U.S.
In the past, asbestos was used as a fire retardant and an insulator.
Other products are now used in its place. The controversy involving
exposure to different forms of asbestos continues.
There are two major types of asbestos: chrysotile and amphibole. It is
thought that exposure to the amphibole form is more likely to cause
mesothelioma. However, chrysotile has been used more frequently, hence
many mesotheliomas are caused by chrysotile.
Removal is taking place in schools and other public buildings
throughout the U.S. The hope is that these measures will greatly
reduce the occurrence of this cancer.
What are the long-term effects of the disease? A mesothelioma is a
highly aggressive tumor that is generally deadly. Current treatment of
malignant mesothelioma is designed to make the person with cancer
comfortable. Although long-term survival cannot usually be expected,
the case of famed paleontologist Stephen Jay Gould is a noted example.
What are the risks to others? Mesothelioma is not contagious and
cannot be passed from one person to another. The exposure to the
asbestos that caused the cancer occurred many years to several decades
before the disease appeared. People who live with asbestos workers
have a higher risk of getting this cancer.
Notable people with mesothelioma
Mesothelioma, though rare, has had a number of notable
patients. Australian anti-racism activist Bob Bellear died in 2005.
British science fiction writer Michael G. Coney, responsible for
nearly 100 works died in 2005. American film and television actor Paul
Gleason, perhaps best known for his portrayal of Principal Richard
Vernon in the 1985 film The Breakfast Club, died in 2006. Mickie Most,
an English record producer, died of mesothelioma in 2003. Paul
Rudolph, an American architect known for his cubist building designs,
died in 1997.
Steve McQueen was diagnosed with peritoneal mesothelioma on December
22, 1979. He was not offered surgery or chemotherapy because doctors
felt the cancer was too advanced. McQueen sought alternative
treatments from clinics in Mexico[citation needed]. He died of a heart
attack on November 7, 1980, in Juárez, Mexico, following cancer
surgery. He may have been exposed to asbestos while serving with the
US Marines as a young adult -- asbestos was then commonly used to
insulate ships' piping -- or because of its use as an insulating
material in car racing suits.
United States Congressman Bruce Vento died of mesothelioma in 2000.
The Bruce Vento Hopebuilder is awarded yearly by his wife at the MARF
symposium to persons or organizations who have done the most to
support mesothelioma research and advocacy.
After a long period of untreated illness and pain, rock and roll
musician and songwriter Warren Zevon was diagnosed with inoperable
mesothelioma in the fall of 2002. Refusing treatments he believed
might incapacitate him, Zevon focused his energies on recording his
final album The Wind including the song Keep me in your heart which
speaks of his failing breath. Zevon died at his home in Los Angeles,
California, on September 7, 2003.
Although life expectancy with this disease is typically limited, there
are notable survivors. In July 1982, Stephen Jay Gould was diagnosed
with peritoneal mesothelioma. After his diagnosis, Gould wrote the
"The Median Isn't the Message," [6] for Discover magazine, in which he
argued that statistics such as median survival are just useful
abstractions, not destiny. Gould lived for another twenty years
eventually succumbing to metastatic adenocarcinoma of the lung, not
mesothelioma.
Author Paul Kraus was diagnosed in June 1997 with peritoneal
mesothelioma. He declined surgery, chemotherapy, and radiation, and
later wrote about the various lifestyle changes and alternative
modalities he has used to sucessfully manage his cancer.
Legal issues
Main article: asbestos and the law
The first lawsuits against asbestos manufacturers were in 1929. Since
then, many lawsuits have been filed against asbestos manufacturers and
employers, for neglecting to implement safety measures after the links
between asbestos, asbestosis, and mesothelioma became known (some
reports seem to place this as early as 1898). The liability resulting
from the sheer number of lawsuits and people affected has reached
billions of dollars. The amounts and method of allocating compensation
have been the source of many court cases, and government attempts at
resolution of existing and future cases.
History
The first lawsuit against asbestos manufacturers was
brought in 1929. The parties settled that lawsuit, and as part of the
agreement, the attorneys agreed not to pursue further cases. It was
not until 1960 that an article published by Wagner et al first
officially established mesothelioma as a disease arising from exposure
to crocidolite asbestos[8]. The article referred to over 30 case
studies of people who had suffered from mesothelioma in South Africa.
Some exposures were transient and some were mine workers. In 1962
McNulty reported the first diagnosed case of malignant mesothelioma in
an Australian asbestos worker[9]. The worker had worked in the mill at
the asbestos mine in Wittenoom from 1948 to 1950.
In the town of Wittenoom, asbestos-containing mine waste was used to
cover schoolyards and playgrounds. In 1965 an article in the British
Journal of Industrial Medicine established that people who lived in
the neighbourhoods of asbestos factories and mines, but did not work
in them, had contracted mesothelioma.
Despite proof that the dust associated with asbestos mining and
milling causes asbestos related disease, mining began at Wittenoom in
1943 and continued until 1966. In 1974 the first public warnings of
the dangers of blue asbestos were published in a cover story called
"Is this Killer in Your Home?" in Australia's Bulletin magazine. In
1978 the Western Australian Government decided to phase out the town
of Wittenoom, following the publication of a Health Dept. booklet,
"The Health Hazard at Wittenoom", containing the results of air
sampling and an appraisal of worldwide medical information.
By 1979 the first writs for negligence related to Wittenoom were
issued against CSR and its subsidiary ABA, and the Asbestos Diseases
Society was formed to represent the Wittenoom victims.
Latest Research
1). Eur J Cardiothorac Surg. 2006 Jan;29(1):14-9. Epub 2005
Dec 15.
Multimodality approach in management of malignant pleural mesothelioma.
Neragi-Miandoab S.
Thoracic and Cardiovascular Surgery, Loyola University Medical Center,
Chicago, Stritch School of Medicine, Maywood, IL, USA. sneragi@yahoo.com
Malignant pleural mesothelioma (MPM) is a solid, locally aggressive
tumor, which has been closely linked to asbestos exposure. The
survival rate without treatment ranges from 4 to 12 months. Response
to chemotherapy and radiation is poor, and surgery is the most
effective therapy. There are currently 3000 new MPM cases per year in
the United States, with the peak incidence in the United States and
Europe expected to occur in the year 2020. The prognosis depends on
the stage of the tumor at the time of diagnosis, its histological
type, lymph node status, and resection margins. While the diagnosis is
often delayed, earlier intervention may improve life expectancy.
Single-modality therapy has not been effective in changing the natural
history of MPM. As a result, multimodality regimens involving surgery
with radiation, chemotherapy, or immunotherapy have been initiated.
Multiple modality approach has demonstrated favorable outcome,
particularly in patients with epithelial histology, negative resection
margins and presence of no metastases to extrapleural lymph nodes.
Cisplatin and mitomycin have demonstrated modest efficacy in
management of distant tumor recurrence. Cisplatin and gemcitabine
regimen as well as cisplatin/pemetrexed followed by 54 Gy of adjuvant
hemithorax radiation have been reported to improve the outcome.
2). Special Issue on mesothelioma: Hematol Oncol Clin North Am. 2005
Dec;19(6):
Several articles, e.g., Gene therapy for malignant pleural
mesothelioma, Antiangiogenic therapies for mesothelioma, An overview
of chemotherapy for mesothelioma., Radiotherapy for mesothelioma,
Multimodality treatments in the management of malignant pleural
mesothelioma: an update, Prognostic factors for mesothelioma. etc
INDEX |