The treatment of malignant mesothelioma (MM) is a particular challenge for the physician. The diffuse nature of the disease makes it difficult for the surgeon to perform a radical resection. Even if technically possible, such extensive resections are usually not curative. The role of two other treatment modalities, radiotherapy and chemotherapy, will be discussed in this chapter.
Radiotherapy
In the past, only anecdotal reports provided some insight on the efficacy of radiotherapy for pleural MM.
Elmes stated that radiotherapy was avoided because it seemed ‘to cause the tumor to grow more rapidly through the chest wall and to involve the skin’.
The first systematic trial of radiotherapy was published in France by Eschwege and Schlienger in 1973.
These authors gave a total dose of 3500–7500 cGy delivered by a 23 MeV betatron in individual doses of 330 cGy three times per week in 14 patients with pleural MM. Anterior and posterior portals were used to include the entire hemithorax, the diaphragm, axillary and supraclavicular areas, and two-thirds of the adjacent mediastinum. Most patients received a total of 4500 cGy. Portals were reduced after that dose in patients who continued radiotherapy. Despite this large volume and the risk of radiation pneumonitis, as well as cardiac and spinal cord injury, tolerance was reported to be acceptable and a favourable effect on pain was noted. Median survival after onset of radiotherapy was 15 months, with a range of 1 to 37 months.
Chemotherapy
Our knowledge of the effects of various chemotherapeutic agents has gradually increased over the past 20 years, although it is still very limited because of the small number of patients, which precludes the systematic evaluation of new agents as well as the conduct of large Phase III type clinical trials. Mesothelioma is a disease which has been poorly responsive to chemotherapy, and there is as yet no standard chemotherapy regimen. In view of the rarity of the disease, the use of laboratory models such as the nude mouse human xenograft system is particularly helpful in selecting the most active agents for clinical trials. These models have generally confirmed the well-known clinical fact that this tumour is resistant to most drugs. There are, however, regimens which have produced occasional good responses, and which do not justify the attitude of total nihilism so common to many oncologists dealing with mesothelioma patients.
Radiotherapy
In the past, only anecdotal reports provided some insight on the efficacy of radiotherapy for pleural MM.
Elmes stated that radiotherapy was avoided because it seemed ‘to cause the tumor to grow more rapidly through the chest wall and to involve the skin’.
The first systematic trial of radiotherapy was published in France by Eschwege and Schlienger in 1973.
These authors gave a total dose of 3500–7500 cGy delivered by a 23 MeV betatron in individual doses of 330 cGy three times per week in 14 patients with pleural MM. Anterior and posterior portals were used to include the entire hemithorax, the diaphragm, axillary and supraclavicular areas, and two-thirds of the adjacent mediastinum. Most patients received a total of 4500 cGy. Portals were reduced after that dose in patients who continued radiotherapy. Despite this large volume and the risk of radiation pneumonitis, as well as cardiac and spinal cord injury, tolerance was reported to be acceptable and a favourable effect on pain was noted. Median survival after onset of radiotherapy was 15 months, with a range of 1 to 37 months.
Chemotherapy
Our knowledge of the effects of various chemotherapeutic agents has gradually increased over the past 20 years, although it is still very limited because of the small number of patients, which precludes the systematic evaluation of new agents as well as the conduct of large Phase III type clinical trials. Mesothelioma is a disease which has been poorly responsive to chemotherapy, and there is as yet no standard chemotherapy regimen. In view of the rarity of the disease, the use of laboratory models such as the nude mouse human xenograft system is particularly helpful in selecting the most active agents for clinical trials. These models have generally confirmed the well-known clinical fact that this tumour is resistant to most drugs. There are, however, regimens which have produced occasional good responses, and which do not justify the attitude of total nihilism so common to many oncologists dealing with mesothelioma patients.
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