On September 30, 1999, I was in attendance for Dr. Scott J. Swanson's lecture concerning advancements in the treatment of mesothelioma, and more specifically, advancements in multimodality therapy. Dr. Swanson gave this presentation during the 1999 Mealey's Asbestos Conference in Boston, Massachusetts. Dr. Swanson is an Associate Chief of Thoracic Surgery and Direction of Lung Transplantation at the Brigham and Women's Hospital in Boston, Massachusetts. Additionally, Dr. Swanson is an Assistant Professor of Surgery at the Harvard Medical School. Most people familiar with the treatment of mesothelioma know the name of Dr. David Sugarbaker. Dr. Sugarbaker is Dr. Swanson's partner. Keeping in mind that I am not a doctor, below are my notes on Dr. Swanson's lecture.
Dr. Swanson began his presentation describing that in the United States there are approximately 2500 new cases per year of diagnosed mesothelioma. He noted that the incidences of mesothelioma are increasing in older men and anticipates that the amount of new mesothelioma cases will peak to 4000 to 5000 per year some time in the next ten years. He described that most of the mesothelioma patients he sees present with dyspnea/pleural effusion (80%), cough (60%), and chest pain (40%), although fewer than five percent had pain in both lungs.
Dr. Swanson described the most common single modality therapies, surgery, radiotherapy and chemotherapy. Single modality therapy is when a doctor treats mesothelioma exclusively with one therapy. Depending how far along a patient is with the disease helps the doctor determine which therapy or therapies are indicated. The process of identifying how far along a person is with this disease is known as clinical staging. Drs. Sugarbaker and Swanson have developed their own staging system as follows:
Stage I: Complete resected disease with pleural envelope
negative for nodules;
Stage II: Positive margins or intrapleural adenopathy;
Stage III: Gross invasion beyond envelope or extrapleural
Stage IV: Distant metastases (very uncommon).
Dr. Swanson lectured on the advancements in multimodality therapy, i.e.; a combination of therapies given to a mesothelioma patient all at once. The current multimodality therapies consist of an extrapleural pneumonectomy, chemotherapy and radiotherapy.
An extrapleural pneumonectomy, as Dr. Swanson described, is the resection of the lung parietal pleural and ipsilateral pericardium and diaphragm. The diaphragm is then reconstructed with Gortex and in those cases where the right side is involved the pericardium is reconstructed with Gortex as well. There is also resection of prior chest tube and biopsy sites and a hiler and ipsilateral and mediastinal lymph node sample is taken.
The extrapleural pneumonectomy is followed by intraoperative intrathoracic/intraperitoneal cisplatin with sodium thiosulfate protection. In other words, these are administered at the time of surgery. Dr. Swanson described how a relatively new technique is to heat the drugs as studies show that heating increases cell permeability and the membrane transport of drugs. Further, neoplastic cells are more sensitive to hyperthermia (heating) than are normal cells and synergism has been demonstrated between hyperthermia and chemotherapy, especially with cisplatin. The rationale for the intraoperative therapy, i.e.; the administration of drugs at the time of surgery directly into the thorax is to attack the residual tumor cells within the hemithorax which become entrapped in fibrin deposits. Dr. Swanson said this procedure was similar to using antibiotics for an infection at the beginning stages of the infection rather than using antibiotics on a full blown infection. These procedures are followed by a postoperative course of chemotherapy and radiotherapy
In deciding which patients are eligible for this surgery, there are essentially six criteria. First, there has to be a diagnosis of mesothelioma by open biopsy. A person must be able to perform the Karnowsky performance status greater than seven; this is essentially a test to determine your physical condition. The patient must have a good heart, kidneys, and be able to survive with one lung. Finally, a chest MRI is done to see if there is any cancer outside of the effected area.
Dr. Swanson went on to lecture that the results of multimodality therapy had been encouraging. Only 3.8% of the patients died within 30 days after the surgery from complications associated with the surgery. The median length of a hospital stay for patients who underwent this procedure was down to seven days on average. The median survival for all patients was approximately 17 months which is encouraging considering that the survival rate for those patients receiving supportive therapy only is four to nine months. More interesting was that patients with epithelial histology, negative resection margins, and negative extrapleural nodes had a median survival of 51 months with a two year survival rate of 68% and five year survival rate of 46%.
All in all, Dr. Swanson's lecture was inspiring. He compared mesothelioma to leukemia in children. At one time, leukemia in children was thought to be incurable and many physicians felt that even seeking a cure was a waste of time. Today, we know that leukemia in children is curable with a very high success rate. Dr. Swanson is dedicated to finding a cure for mesothelioma.
Written by Michael P. Delaney, Esq.
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