Mesothelioma : Facts, Symptoms, Diagnosis & Treatment Types - Mesothelioma cancer of the lining of the lung or the lining of the abdomen is very different from a lung cancer. A typical lung cancer grows as a single identifiable nodule. Or mass which is anywhere from the size of a grape to the size of a baseball or larger when discovered. Because most lung cancer grows as a solitary defined mass. Sometimes it can be cut out and followed up with chemotherapy. Or radiation which results in removing and killing off all of the lung cancer cells so that the cancer. Does not return.
So far, medical science has only very, very rarely been able to accomplish the same thing for persons with mesothelioma. The reasons for this is that mesothelioma grows on the lining of the lung (or the lining of the abdomen). As a diffuse multi-site tumor with tumor nodules being spread on a wide area of the pleura. Even when an individual is able to undergo surgery for removal of the entire pleura. Lung on the side where the mesothelioma is located, and parts of the diaphragm. This almost never results in total removal of all of the cancer cells.
- 1 Facts About Mesothelioma
- 2 Mesothelioma Symptoms
- 3 Mesothelioma Diagnosis
- 4 Mesothelioma Cases
- 5 Picture of Mesothelioma
- 5.1 1. Mesothelioma
- 5.2 2. Mesotheliomas Have Either Spindle Cells
- 5.3 3. Asbestosis
- 5.4 4. Asbestosis - Ferruginous body
- 5.5 5. Fibrous Pleural Plaque
- 5.6 6. Micrograph of a Pleural Plaque
- 5.7 7. Silicotic Nodule
- 5.8 8. Coal Worker's Pneumoconiosis
- 5.9 9. Silicosis and Coal Workers' Pneumoconiosis
- 5.10 10. Silica Crystals in Silicosis of Lung, Polarized
- 5.11 11. Fat Embolism Syndrome
- 5.12 12. Amniotic Fluid Emboli
- 5.13 13. Hypersensitivity Pneumonitis
- 5.14 14. Thermophilic Actinomycetes
- 5.15 15. Silo Filler's Disease
- 5.16 16. Idiopathic Pulmonary Fibrosis
- 5.17 17. Trichrome Stain Kit
- 5.18 18. Pulmonary Fibrosis in Sarcoidosis
- 5.19 19. Diffuse Alveolar Damage
- 5.20 20. Hyaline Membranes
- 5.21 21. Honeycomb Lung
- 5.22 22. Peripheral Pulmonary Artery
- 5.23 23. Desquamative Interstitial Pneumonitis (DIP)
- 6 Mesothelioma Treatment Types
Facts About Mesothelioma
Mesothelioma cancer does not act the same way in all people. In addition, a person's general state of health can have a lot to do with how they fare with the mesothelioma.
There are different cell types of mesothelioma. Of the three cell types of mesothelioma, epithelial mesothelioma seems to grow the slowest. Sarcomatous or spindle-cell mesotheliomas seem to grow the fastest and biphasic mesotheliomas. Which have characteristics of both epithelial and sarcomatous mesotheliomas seem to grow at a rate in between those two. Life expectancy from the date of diagnosis with mesothelioma to death varies from as short as several months to five years or in some cases longer. Age at time of diagnosis and overall general health make a big difference in how long a person lives.
A few cases are reported of persons alive five and more years after diagnosis. More of these cases are occurring as time goes on and more is known about how to try and fight the cancer.
Mesothelioma cancer is usually diagnosed after a person develops breathing difficulty, shortness of breath, chest discomfort, chest pain, and fatigue. When a person goes to the doctor for the first time with these symptoms. The doctor will usually take a chest x-ray and listen to the chest. Many times the chest x-ray will show a large area of white which indicates an accumulation of fluid. It is very common for mesothelioma to cause fluid to accumulate in the pleural space (a pleural effusion).
The pleural space is the area between the outside lining of the lung and the inside lining of the chest wall. In a normal person, the pleura which lines the chest rubs up against the pleura which lines the chest wall. Each of these pleura are about as thick as a piece of saran wrap. There is a very tiny amount of fluid which coats each of the pleura so that when they rub up against one another as a person inhales and exhales, there will be no friction or irritation.
When a mesothelioma develops, the pleura often becomes much thickened and studded with tumor nodules. Part of the body's response to the presence of the tumor is to weep fluid into the pleural space. As the fluid collects in the pleural space, it compresses the lung. Making it harder and harder for a person to breathe and causing more and more shortness of breath. If the mesothelioma has produced fluid, it is usually possible for the doctor to drain the fluid out of the pleural space. (thoracentesis) giving immediate relief of the symptoms of the mesothelioma. When the fluid is drained, the lung is able to return to close to normal size and it becomes immediately easier for the person to breathe.
A diagnosis of mesothelioma can sometimes be made just by looking at the cells which are contained in the pleural fluid. Sometimes the specimen of pleural fluid will contain some of the cancer cells which have sloughed off of the mesothelioma tumor on the lining of the lung. If some of these cells are found in the pleural fluid, then the pathologist can make a firm diagnosis of mesothelioma just by looking at the pleural fluid specimen. Many times, however, the pleural fluid does not contain cells of the mesothelioma cancer. This does not mean that the cancer is not there. Rather, it simply means that a better specimen needs to be obtained in order to determine whether or not a person has mesothelioma.
If the specimen of pleural fluid does not provide any information as to the presence of mesothelioma, doctors will often move on to suggest that there be a pleural biopsy. Doctors can attempt to obtain a specimen of the pleura by doing a needle biopsy. The needle biopsy involves the insertion of a needle through the outside of the chest, between the ribs, through the chest wall and into the pleura in order to snag a small piece of tissue.
If the needle is put into an area where the mesothelioma tumor is growing and is able to retrieve some of those cells in the small piece of tissue which is extracted. Then the pathologist will be able to make a diagnosis of mesothelioma. Sometimes, a person with mesothelioma will have repeated needle biopsy and still there will be no diagnosis of mesothelioma by the pathologist. This can occur if the needle biopsy does not happen to take a specimen from the area where the cancer is growing.
The diagnosis of mesothelioma is not always straight forward. Only about 2,000-3,000 cases of mesothelioma occur every year. (By comparison, 2 million or more Americans die every year.) Most mesotheliomas occur in persons who live in urban areas where there is the greatest opportunity for exposure to asbestos. Thus, community hospital pathologists rarely have an opportunity to see a person with mesothelioma as part of their practice.
Because of this, community hospital pathologists will often send tissue specimens suspected of being mesothelioma to other pathologists with an expertise in the diagnosis of mesothelioma for a second opinion. Most teaching hospitals in large metropolitan areas have pathologists on staff who are more than competent to diagnose mesothelioma. In addition, there are two other organizations to which community hospital pathologists can go for second opinions when it comes to the diagnosis of mesothelioma.
Picture of Mesothelioma
The dense white encircling tumor mass is arising from the visceral pleura and is a mesothelioma. These are big bulky tumors that can fill the chest cavity.The risk factor for mesothelioma is asbestos exposure. However, mesothelioma is rare even in persons with asbestos exposure. Asbestosis more commonly predisposes to bronchogenic carcinomas, increasing the risk by a factor of five. Smoking increases the risk for lung cancer by a factor of ten. Thus, smokers with a history of asbestos exposure have a risk 50 fold greater likelihood of for developing lung cancer. Mesothelioma
2. Mesotheliomas Have Either Spindle Cells
Mesotheliomas have either spindle cells or plump rounded cells forming gland-like configurations, as seen here at high power microscopically. They are very difficult to diagnose cytologically. Mesothelioma
This is the causative agent for asbestosis, a long, thin asbestos fiber. Some houses, business locations, and ships still contain building products with asbestos, particularly insulation materials. So care must be taken when doing remodelling or reconstruction. Mesothelioma
4. Asbestosis - Ferruginous body
The asbestos fiber becomes coated with iron and calcium, which is why it is often referred to as a "ferruginous body" as seen here with an iron stain. Ingestion of these fibers by macrophages sets off a fibrogenic response via release of growth factors that promote collagen deposition by fibroblasts.
5. Fibrous Pleural Plaque
Another gross lesion typical for pneumoconioses, and asbestosis in particular, is a fibrous pleural plaque. Seen here on the pleural side of the diaphragmatic leaves are several tan-white pleural plaques.
6. Micrograph of a Pleural Plaque
Microscopically, the fibrous pleural plaque is composed of dense layers of collagen. Mesothelioma
7. Silicotic Nodule
A silicotic nodule within lung parenchyma is seen here. It is composed mainly of bundles of interlacing pink collagen. There is a minimal inflammatory reaction. The greater the degree of exposure to silica and increasing length of exposure determine the amount of silicotic nodule formation and the degree of restrictive lung disease. Silicosis increases the risk for lung carcinoma only about 2-fold. Mesothelioma
8. Coal Worker's Pneumoconiosis
Anthracotic pigment ordinarily is not fibrogenic, but in massive amounts (as in "black lung disease" in coal miners) a fibrogenic response can be elicited to produce the "coal worker's pneumoconiosis" seen here. Mesothelioma
9. Silicosis and Coal Workers' Pneumoconiosis
By polarized light microscopy can be seen the etiology for most pneumoconiosis (even those in coal miners)--silica crystals. Here are seen bright white crystals of varying sizes. The silica induces a fibrogenic response by macrophages to produce the nodular foci of collagen deposition. Mesothelioma
10. Silica Crystals in Silicosis of Lung, Polarized
Bright white collections of polarizable crystals are seen here, but are diffuse and centered around vascular spaces. This is the lung of a patient with a long history of intravenous drug use. Only about 1% of such persons get a significant degree of pulmonary fibrosis. The crystals represent talc that is used to to dilute the injected drug. Mesothelioma
11. Fat Embolism Syndrome
The rounded holes that appear in the vascular spaces here in the lung are fat emboli. Fat embolization syndrome occurs most often following trauma with fracture of long bones that releases fat globules into the circulation which are trapped in pulmonary capillaries. Cumulatively, they have the same effect as a large saddle pulmonary embolus. Mesothelioma
12. Amniotic Fluid Emboli
This is a rare finding that may complicate a term pregnancy at delivery. Seen here in a pulmonary artery branch is an amniotic fluid embolus that has layers of fetal squames. Amniotic fluid embolization can have the same outcome as a large saddle pulmonary embolus. Mesothelioma
13. Hypersensitivity Pneumonitis
This is an example of hypersensitivity pneumonitis that can occur when there is an inhaled organic dust that produces a localized for of type III hypersensitivity (Arthus) reaction from antigen-antibody complexes. The symptoms of dyspnea, coughing, and fever abate when the affected person leaves the environment where the offending antigen is located. There are no major long-term complications.
14. Thermophilic Actinomycetes
One form of hypersensitivity pneumonitis is known as farmer's lung because the farmer inhales thermophilic actinomycetes in moldy hay that set off the reaction. Bird dust (bird fancier's disease) and molds in air conditioners may produce similar problems. The bales in this field near Sterling are of good quality and less likely to produce this disease. Mesothelioma
15. Silo Filler's Disease
Farmer's lung must be distinguished from "silo filler's disease" which is an acute chemical pneumonitis due to toxic gases released from fermenting silage into the atmosphere inside the silo (an example of which is seen here on this farm between Edinburgh and Glasgow). Mesothelioma
16. Idiopathic Pulmonary Fibrosis
This is an example of pulmonary fibrosis. Some cases of restrictive lung disease have no known etiology--this is, they are known as idiopathic pulmonary fibrosis. The alveolitis that produces fibroblast proliferation and collagen deposition is progressive over time. Mesothelioma
17. Trichrome Stain Kit
A trichrome stain highlights the collagenous connective tissue of pulmonary fibrosis in blue.
18. Pulmonary Fibrosis in Sarcoidosis
One cause for pulmonary intersitital fibrosis is sarcoidosis. In addition to increased interstitial markings, the chest radiograph may display prominent hilar lymphadenopathy (from non-caseating granulomatous inflammation) as shown here. Mesothelioma
19. Diffuse Alveolar Damage
Here is an example of diffuse alveolar damage in which the lung is diffusely firm and rubbery. Clinically, this is known as adult respiratory distress syndrome (ARDS). Mesothelioma
20. Hyaline Membranes
This is the microscopic appearance of diffuse alveolar damage (DAD) in the lung. DAD is simply the final common pathway for a variety of severe lung injuries. In early DAD, there are hyaline membranes lining alveoli. Later, type II pneumonocyte proliferation and then interstitial inflammation and fibrosis are seen. High oxygen tensions needed to treat the hypoxia resulting from DAD and its etiologies further potentiates this disease. Mesothelioma
21. Honeycomb Lung
Regardless of the etiology for restrictive lung diseases, many eventually lead to extensive fibrosis. The gross appearance, as seen here in a patient with organizing diffuse alveolar damage Is known as "honeycomb" lung because of the appearance of the irregular air spaces between bands of dense fibrous connective tissue. Mesothelioma
22. Peripheral Pulmonary Artery
Both restrictive and obstructive lung diseases can affect the pulmonary arterial circulation. The loss of normal lung parenchyma leads to pulmonary hypertension that leads to thickening of the small arteries along with reduplication to form a plexiform lesion, as seen here in a peripheral pulmonary artery.
23. Desquamative Interstitial Pneumonitis (DIP)
This is an example of an uncommon pattern of injury called desquamative interstitial pneumonitis (DIP) that is characterized by a proliferation of alveolar macrophages (not desquamated type II cells as originally thought) filling the alveoli. Though some of these cases go on to diffuse interstitial fibrosis, many of the patients respond better to corticosteroid therapy than patients with other causes for interstitial fibrosis. Mesothelioma
Smoking may be related to several interstitial lung diseases including the DIP shown here, as well as respiratory bronchiolitis, pulmonary Langerhans cell histiocytosis (eosinophilic granuloma of lung), and idiopathic pulmonary fibrosis. [Washko GR, Hunninghake GM, Fernandez IE, et al. Lung Volumes and Emphysema in Smokers with Interstitial Lung Abnormalities. N Engl J Med 2011; 364:897-906].
Mesothelioma Treatment Types
Persons with mesothelioma searching for help have a number of options. For some mesothelioma patients, surgical removal of the tumor, pleura, lung and portions of the diaphragm accompanied after surgery by chemotherapy, radiation therapy or both, may lead to prolongation of life. In some cases, surgery cannot or should not be performed. In these situations, oncologist (cancer doctors) may recommend either chemotherapy or radiation therapy or both. Mesothelioma
Removal of Fluid (Thoracentesis)
The pleural fluid can be removed by inserting a needle through the chest wall and between the ribs into the area where the fluid is located. The fluid is drained out and the lung re-expands, thereby giving the patient immediate relief from the shortness of breath which is being experienced. It is not unusual in cases of mesothelioma for the fluid to re-occur. In some patients, the fluid can come back over and over and over again.
Sometimes doctors will attempt to prevent the fluid from reoccurring by fusing the pleura on the outside of the lung with the pleura on the inside of the chest. By fusing the two together, the doctor is able to eliminate the space in which the fluid might otherwise collect. The two pleura can be fused together through the use of medication (tetracycline or doxycycline) or also by the use of surgical talc. Before a patient with mesothelioma or suspected of having mesothelioma goes through this procedure (known as pleurodesis), the patient should consult with the treating doctor to see if the use of this procedure will make it more difficult or impossible for the patient to consider surgical intervention later on, if that is one of the options the patient wishes to consider. Mesothelioma
Surgical intervention in mesothelioma cases is a serious and complicated operation. The surgeon may remove the lining of the lung (pleura), the lining of the peritoneum, portions of the lung, diaphragm, and other tissues as well. Careful investigation and consideration should be given before participating in such surgery. The credentials of the physician and treating hospital involved should be checked. Hospitals associated with medical schools in major urban areas will likely have surgeons with some experience in performing surgery for mesothelioma patients.
In addition, there are a number of surgeons around the country who have been using surgical intervention in mesothelioma cases with some success. Success means that they have been able to extend the life of their patients and improve their quality of life. I do not think that there is any doctor anywhere who will say that surgery provides a cure for mesothelioma. Our mesothelioma clients have had experience with the following surgeons and hospitals.
Generally, I have found that the younger the person with mesothelioma, the more likely they are to have positive results from surgery. In addition, the better the overall health of the person at the time of the diagnosis of mesothelioma, the more likely that surgery might be of some assistance.
Though the surgeon who conducts this operation may be able to cut out all of the mesothelioma tumor which can be seen, there is almost always microscopic mesothelioma cancer cells left behind. That is why an individual who undergoes this surgery typically goes through either chemotherapy or radiation therapy (or both) after the surgery in order to try and kill the microscopic cancer cells which have been left behind after the operation has taken place.
Chemotherapy and/or radiation can kill many of the cancer cells which remain after the surgery is done but again, neither chemotherapy nor radiation has much of a chance of killing all of the mesothelioma cancer cells. Thus, mesothelioma almost always reoccurs even after surgery, chemotherapy and radiation therapy. What each of these treatments for mesothelioma may offer, in some cases, is an increase in life expectancy and an increase in quality of life for a period of time. Mesothelioma
Radiation therapy is also used in treating malignant mesothelioma. It uses high-energy x-rays to try and kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes in the area where the cancer cells are found (internal radiation therapy). Radiation therapy can be used both to try and kill or treat the cancer and also for pain control.
Chemotherapy uses drugs (chemicals) to try and kill mesothelioma cancer cells. Chemotherapy may be taken by pill, by injection or by intravenous drip or pump. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill mesothelioma cancer cells throughout the body. In mesothelioma, chemotherapy may be put directly into the chest (intra pleural chemotherapy).