Pleural mesothelioma. Modern treatment tactics

Mesothelioma is a malignant tumor was first described in 1870. It is more common lesion Pleven-ry, than the peritoneum, with a predominance of right-sided. Men suffer more than women, in co-ratio of 8: 1. Mesothelioma can occur at any age, even in children 2-4 years. In the etiology of mesothelioma primary importance is the duration of exposure to asbestos and erionite mineral used in construction practice. Etiological factors are genetic predisposition, as well as simian virus SV40.

According to the histological WHO classification (1999), malignant mesothelioma are divided into epithelial-WIDE, sarkomatoidnye and mixed (biphasic). The most unfavorable is frequent sarcoma tumor-toidny option. Pleural effusion occurs in 60-80% of patients, but gradually growing tumor can cause complete obliteration of the pleural cavity.

The prognosis of pleural mesothelioma unfavorable, the median survival of patients (symptomatic treatment) is 7 months. Surgical treatment in the amount of pleurectomy or plevropnevmonektomii is rare, with localized forms, only in 7-10% of patients. After plevropnevmonektomy operative mortality reaches 14-15%, significantly higher than the (minimum) plevrektomy mortality. Expectancy-sti life do not differ after these operations: the median survival corresponds to 9-21 months .; 2-year survival rate is 11-45% (Giaccone G., 2002; Rahman M. et al, 2003.). Improving long-term results of surgical treatment (primarily plevropnevmonektomy) associated with adjuvant chemotherapy.

Experience of surgical, combined treatment (surgery + chemotherapy + radiotherapy) * allowed to develop the following recommendations for pleural mesothelioma: extrapleural pneumonectomy Execution (plevropnevmonektomii) holding in 4-6 weeks up to 6 cycles of chemotherapy with the appointment of platinum drugs, followed by radiation therapy to the area remote lung and mediastinum. Direct mortality in different comparison groups accounted for 5-22%, median - 21 months, 2-5-year survival -. 45 and 22%, respectively. Factors most favorable prognosis are the type of epithelial tumors, as well as the absence of metastases. Radiotherapy (ODS 50 Gy.) Reduces the pain, but does not increase the duration of life (increased dose, as well as a combination of chemotherapy and radiotherapy does not improve survival).

The efficiency of modern chemotherapy for pleural mesothelioma rarely exceeds 20%. Marked tumor regression and objective improvement in the application of cisplatin, tsikloplatama, mitomycin, raltitreksida (tomudeksa), etoposide, carboplatin, ifosfamide, vinorelbine, gemcitabine (Gemzar), pemetrexed (Alimta).

Combination chemotherapy is carried out under the schemes: doxorubicin + cyclophosphamide, doxorubicin, ifosfamide, doxorubicin and cisplatin + - mitomycin C and cisplatin + kampto mitomycin C, gemcitabine and cisplatin (carboplatin) Gemcitabine + Alimta, Alimta and cisplatin (carboplatin). Last 3 schemes are considered standard treatment for pleural mesothelioma.

In the presence of pleural effusion may intrapleural administration of cytostatic drugs or biotherapy with the aim of halting or slowing the accumulation of fluid. For this purpose, cisplatin, bleomycin, and - interferon and interleukin-2. Possibilities of photodynamic therapy investigated.

In addition, in clinical trials targeted therapies: Avastin, Iressa, Gleevec, thalidomide, and others, which may increase the survival rate.. Among the targeted agents should pay attention to inhibitors of vascular endothelial growth factor. It is noted that for pleural mesothelioma high level expression of vascular endothelial growth factor correlates with increased capillary density and low survival. In this regard, with mesothelioma semaksanib study, bevacizumab (Ava-Springsteen) and thalidomide.

* References: 1. Rice T. W., Adelstein D.J., Kirby T.J, et al. Aggressive multimodality therapy for malignant mesothelioma. Ann Thorac Surg, 1994; 58: 24-9. 2. Sugarbaker D.J., Garcia J. P., Richards W.G. et al. Extrapleural pneumonectomy in the multimodality therapy of malignant pleural mesothelioma. Results in 120 consecutive patients. Ann Surg, 1996; 224: 288-96. 3. Sugarbaker D.J., Garcia J.P. Multimodality therapy for malignant pleural mesothelioma. Chest, 1997; 112: 272-5

Vseobuch. Summary materials:

Pleural mesothelioma - a relatively rare tumor characterized by a diffuse infiltrative growth. The risk is much higher in patients with asbestosis. The epidemiology of Russia this neoplasm is not given enough attention. Meanwhile, according to the literature, in the US, where professionally exposed to asbestos 7-8 million. People, the incidence of malignant mesothelioma is 0.1-0.2 per 100 thousand inhabitants, and increasing every year (peritoneum and pleura are affected equally often). Since 1976 in France, this pathology attributed to occupational diseases (B. Saillard et al., 1977). The latency period of malignant mesothelioma is 20-30 years.

The pathogenesis of pleural mesothelioma has not been studied, however, it found that asbestos fibers have a tropism for the serous membrane. Respiratory they migrate to the pleura, which can accumulate in large quantities and serve as a trigger for the development of tumors. Thanks to lymph flow, directed towards the parietal pleura, the tumor cells are implanted in her and gradually spread over the entire surface. Thus, in the neoplastic process involves both visceral and parietal pleura, which leads to disruption of lymph circulation, the rapid accumulation of fluid in the pleural cavity.

Of course, the diagnosis of pleural mesothelioma is difficult. Its clinical manifestations are non-specific, depending on the extent of tumor and location of the lesion.

The diagnosis of pleural mesothelioma is set with pleural biopsy, electron microscopy and immunohistochemistry. Surgical treatment of mesothelioma is rare (in 7-10% of patients), and 2-year survival rate after surgery is only 10-35%. Radiation therapy is commonly performed to reduce pain and has no effect on survival. Among cytostatic active against mesothelioma, note platinum derivatives, gemcitabine, anthracyclines. The use of these drugs leads to the objective effect in 20-48% of patients. Note the combination of gemcitabine and cisplatin (carboplatin), doxorubicin and cisplatin + mitomycin C; cisplatin and Alimta. Perspective can also be a combination of new cytostatic agents and their combination with targeted agents. Important prognostic factors include young age, epithelioid type of tumor, as well as the effect of adjuvant chemotherapy after radical plevropnevmonektomii.