Malignant Mesothelioma Treatment (PDQ®): Treatment - Patient Information [NCI]
General Information About Malignant Mesothelioma
Malignant mesothelioma is a disease in which malignant (cancer) cells form in the lining of the chest or abdomen.
Malignant mesothelioma is a disease in which cancer cells are found in the pleura (the thin layer of tissue that lines the chest cavity and covers the lungs) or the peritoneum (the thin layer of tissue that lines the abdomen and covers most of the organs in the abdomen). Malignant mesothelioma may also form in the heart or testicles, but this is rare.
Malignant mesothelioma forms in the tissue that lines the chest or abdomen, including the pleura (the tissue that lines the chest cavity and covers the lungs) and the peritoneum (the tissue that lines the abdomen and covers most of the organs in the abdomen). Malignant mesothelioma may also form in the pericardium (the tissue that surrounds the heart) or the testicles, but this is rare.
Being exposed to asbestos can affect the risk of malignant mesothelioma.
Anything that increases the chance of getting a disease is called a risk factor. Not every person with one or more of these risk factors will develop malignant mesothelioma, and it can develop in people who don't have any known risk factors. Talk to your doctor if you think you may be at risk.
Most people with malignant mesothelioma have worked or lived in places where they inhaled or swallowed asbestos. After being exposed to asbestos, it usually takes a long time for malignant mesothelioma to form. Living with a person who works near asbestos is also a risk factor for malignant mesothelioma.
Signs and symptoms of malignant mesothelioma include shortness of breath and pain under the rib cage.
Sometimes the cancer causes fluid to collect in the chest or in the abdomen. Signs and symptoms may be caused by the fluid, malignant mesothelioma, or other conditions. Check with your doctor if you have any of the following:
- Trouble breathing.
- Cough.
- Pain under the rib cage.
- Pain or swelling in the abdomen.
- Lumps in the abdomen.
- Constipation.
- Problems with blood clots (clots form when they shouldn't).
- Weight loss for no known reason.
- Feeling very tired.
Tests that examine the inside of the chest and abdomen are used to diagnose malignant mesothelioma.
Sometimes it is hard to tell the difference between malignant mesothelioma in the chest and lung cancer.
In addition to asking about your personal and family health history and doing a physical exam, your doctor may perform the following tests and procedures:
- Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
X-ray of the chest. X-rays are used to take pictures of organs and bones of the chest. X-rays pass through the patient onto film. - CT scan (CAT scan): A procedure that makes a series of detailed pictures of the chest and abdomen, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
- Biopsy: The removal of cells or tissues from the pleura or peritoneum so they can be viewed under a microscope by a pathologist to check for signs of cancer.
Procedures used to collect the cells or tissues include the following:
- Fine-needle (FNA) aspiration biopsy of the lung: The removal of tissue or fluid using a thin needle. An imaging procedure is used to locate the abnormal tissue or fluid in the lung. A small incision may be made in the skin where the biopsy needle is inserted into the abnormal tissue or fluid, and a sample is removed.
Fine-needle aspiration biopsy of the lung. The patient lies on a table that slides through the computed tomography (CT) machine, which takes x-ray pictures of the inside of the body. The x-ray pictures help the doctor see where the abnormal tissue is in the lung. A biopsy needle is inserted through the chest wall and into the area of abnormal lung tissue. A small piece of tissue is removed through the needle and checked under the microscope for signs of cancer. - Thoracoscopy: An incision (cut) is made between two ribs and a thoracoscope (a thin, tube-like instrument with a light and a lens for viewing) is inserted into the chest.
- Thoracotomy: An incision (cut) is made between two ribs to check inside the chest for signs of disease.
- Peritoneoscopy: An incision (cut) is made in the abdominal wall and a peritoneoscope (a thin, tube-like instrument with a light and a lens for viewing) is inserted into the abdomen.
- Open biopsy: A procedure in which an incision (cut) is made through the skin to expose and remove tissues to check for signs of disease.
The following tests may be done on the cells and tissue samples that are taken:
- Cytologic exam: An exam of cells under a microscope to check for anything abnormal. For mesothelioma, fluid is taken from the chest or from the abdomen. A pathologist checks the fluid for signs of cancer.
- Immunohistochemistry: A laboratory test that uses antibodies to check for certain antigens (markers) in a sample of a patient's tissue. The antibodies are usually linked to an enzyme or a fluorescent dye. After the antibodies bind to a specific antigen in the tissue sample, the enzyme or dye is activated, and the antigen can then be seen under a microscope. This type of test is used to help diagnose cancer and to help tell one type of cancer from another type of cancer.
- Electron microscopy: A laboratory test in which cells in a sample of tissue are viewed under a high-powered microscope to look for certain changes in the cells. An electron microscope shows tiny details better than other types of microscopes.
- Fine-needle (FNA) aspiration biopsy of the lung: The removal of tissue or fluid using a thin needle. An imaging procedure is used to locate the abnormal tissue or fluid in the lung. A small incision may be made in the skin where the biopsy needle is inserted into the abnormal tissue or fluid, and a sample is removed.
Certain factors affect prognosis (chance of recovery) and treatment options.
The prognosis and treatment options depend on the following:
- The stage of the cancer.
- The size of the tumor.
- Whether the tumor can be removed completely by surgery.
- The amount of fluid in the chest or abdomen.
- The patient's age.
- The patient's activity level.
- The patient's general health, including lung and heart health.
- The type of mesothelioma cells and how they look under a microscope.
- The number of white blood cells and how much hemoglobin is in the blood.
- Whether the patient is male or female.
- Whether the cancer has just been diagnosed or has recurred (come back).
Stages of Malignant Mesothelioma
After malignant mesothelioma has been diagnosed, tests are done to find out if cancer cells have spread to other parts of the body.
The process used to find out if cancer has spread outside the pleura or peritoneum is called staging. The gathered from the staging process determines the stage of the disease. It is important to know whether the cancer has spread in order to plan treatment.
The following tests and procedures may be used in the staging process:
- CT scan (CAT scan): A procedure that makes a series of detailed pictures of the chest and abdomen, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
- PET scan (positron emission tomography scan): A procedure to find cancer cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
- MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
- Endoscopic ultrasound (EUS): A procedure in which an endoscope is inserted into the body. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. A probe at the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure is also called endosonography. EUS may be used to guide fine-needle aspiration (FNA) biopsy of the lung, lymph nodes, or other areas.
Endoscopic ultrasound-guided fine-needle aspiration biopsy. An endoscope that has an ultrasound probe and a biopsy needle is inserted through the mouth and into the esophagus. The probe bounces sound waves off body tissues to make echoes that form a sonogram (computer picture) of the lymph nodes near the esophagus. The sonogram helps the doctor see where to place the biopsy needle to remove tissue from the lymph nodes. This tissue is checked under a microscope for signs of cancer. - Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for signs of disease. Small incisions (cuts) are made in the wall of the abdomen and a laparoscope (a thin, lighted tube) is inserted into one of the incisions. Other instruments may be inserted through the same or other incisions to perform procedures such as taking tissue samples to be checked under a microscope for signs of disease.
- Lymph node biopsy: The removal of all or part of a lymph node. A pathologist views the lymph node tissue under a microscope to check for cancer cells.
- Mediastinoscopy: A surgical procedure to look at the organs, tissues, and lymph nodes between the lungs for abnormal areas. An incision (cut) is made at the top of the breastbone and a mediastinoscope is inserted into the chest. A mediastinoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue or lymph node samples, which are checked under a microscope for signs of cancer.
There are three ways that cancer spreads in the body.
Cancer can spread through tissue, the lymph system, and the blood:
- Tissue. The cancer spreads from where it began by growing into nearby areas.
- Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
- Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.
Cancer may spread from where it began to other parts of the body.
When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.
- Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
- Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.
The metastatic tumor is the same type of cancer as the primary tumor. For example, if malignant mesothelioma spreads to the brain, the cancer cells in the brain are actually malignant mesothelioma cells. The disease is metastatic malignant mesothelioma, not brain cancer.
The following stages are used for malignant mesothelioma of the lung:
Stage I
Stage I is divided into stages IA and IB:
- In stage IA, cancer is found in the inside lining of the chest wall on one side of the chest. On the same side of the chest, cancer may also be found in one or more of the following:
- The thin layer of tissue that covers the lung.
- The thin layer of tissue that covers the organs between the lungs.
- The thin layer of tissue that covers the top of the diaphragm.
- In stage IB, cancer is found in the inside lining of the chest wall, and in each of the thin layers of tissue that cover the lung, the organs between the lungs, and the top of the diaphragm on one side of the chest. On the same side of the chest, cancer has also spread into one or more of the following:
- Diaphragm.
- Lung tissue.
- Tissue between the ribs and the inside lining of the chest wall.
- Fat in the area between the lungs.
- Soft tissues of the chest wall.
- Sac around the heart.
Stage II
In stage II, cancer is found in the inside lining of the chest wall on one side of the chest. On the same side of the chest, cancer may also be found in one or more of the following:
- The thin layer of tissue that covers the lung.
- The thin layer of tissue that covers the organs between the lungs.
- The thin layer of tissue that covers the top of the diaphragm.
Cancer has spread to lymph nodes along the center of the chest on the same side of the chest as the tumor.
or
Cancer is found in the inside lining of the chest wall, and in each of the thin layers of tissue that cover the lung, the organs between the lungs, and the top of the diaphragm on one side of the chest. On the same side of the chest, cancer has also spread into one or both of the following:
- Diaphragm.
- Lung tissue.
Cancer has spread to lymph nodes along the center of the chest on the same side of the chest as the tumor.
Stage III
Stage III is divided into stages IIIA and IIIB.
- In stage IIIA, cancer is found in the inside lining of the chest wall, and in each of the thin layers of tissue that cover the lung, the organs between the lungs, and the top of the diaphragm on one side of the chest. On the same side of the chest, cancer has also spread into one or more of the following:
- Tissue between the ribs and the inside lining of the chest wall.
- Fat in the area between the lungs.
- Soft tissues of the chest wall.
- Sac around the heart.
Cancer has spread to lymph nodes along the center of the chest on the same side of the chest as the tumor.
- In stage IIIB, cancer is found in the inside lining of the chest wall, and may also be found in the thin layers of tissue that cover the lung, the organs between the lungs, and/or the top of the diaphragm on one side of the chest. On the same side of the chest, cancer may have also spread into one or more of the following:
- Diaphragm.
- Lung tissue.
- Tissue between the ribs and the inside lining of the chest wall.
- Fat in the area between the lungs.
- Soft tissues of the chest wall.
- Sac around the heart.
Cancer has spread to lymph nodes above the collarbone on either side of the chest or cancer has spread to lymph nodes along the center of the chest on the opposite side of the chest as the tumor.
or
Cancer is found in the inside lining of the chest wall, and in each of the thin layers of tissue that cover the lung, the organs between the lungs, and the top of the diaphragm on one side of the chest. Cancer has also spread to one or more of the following:
- The chest wall and may be found in the rib.
- Through the diaphragm into the peritoneum.
- The tissue lining the chest on the opposite side of the body as the tumor.
- The organs in the area between the lungs (esophagus, trachea, thymus, blood vessels).
- The spine.
- Through the sac around the heart or into the heart muscle.
Cancer may have spread to lymph nodes.
Stage IV
In stage IV, cancer has spread to the tissue covering the lung or the lung on the opposite side of the chest, peritoneum, bones, liver, lymph nodes outside the chest, or to other parts of the body.
Malignant mesothelioma can recur (come back) after it has been treated.
The cancer may come back in the chest or abdomen or in other parts of the body.
Treatment Option Overview
There are different types of treatment for patients with malignant mesothelioma.
Different types of treatments are available for patients with malignant mesothelioma. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.
The following types of treatment are used:
Surgery
The following surgical treatments may be used for malignant mesothelioma in the chest:
- Wide local excision: Surgery to remove the cancer and some of the healthy tissue around it.
- Pleurectomy and decortication: Surgery to remove part of the covering of the lungs and lining of the chest and part of the outside surface of the lungs.
- Extrapleural pneumonectomy: Surgery to remove one whole lung and part of the lining of the chest, the diaphragm, and the lining of the sac around the heart.
- Pleurodesis: A surgical procedure that uses chemicals or drugs to make a scar in the space between the layers of the pleura. Fluid is first drained from the space using a catheter or chest tube and the chemical or drug is put into the space. The scarring stops the build-up of fluid in the pleural cavity.
After the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.
Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. External radiation therapy uses a machine outside the body to send radiation toward the area of the body with cancer. It may also be used as palliative therapy to relieve symptoms and improve quality of life.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the chest or peritoneum, the drugs mainly affect cancer cells in those areas (regional chemotherapy). Combination chemotherapy is the use of more than one anticancer drug.
Hyperthermic intraperitoneal chemotherapy is used in the treatment of mesothelioma that has spread to the peritoneum (tissue that lines the abdomen and covers most of the organs in the abdomen). After the surgeon removes all the cancer that can be seen, a solution containing anticancer drugs is heated and pumped into and out of the abdomen to kill cancer cells that remain. Heating the anticancer drugs may kill more cancer cells.
The way the chemotherapy is given depends on the type and stage of the cancer being treated.
See Drugs Approved for Malignant Mesothelioma for more information.
Immunotherapy
Immunotherapy is a treatment that uses the patient's immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body's natural defenses against cancer.
The following types of immunotherapy are being used in the treatment of malignant mesothelioma:
- Immune checkpoint inhibitor therapy: Some types of immune cells, such as T cells, and some cancer cells have certain proteins, called checkpoint proteins, on their surface that keep immune responses in check. When cancer cells have large amounts of these proteins, they will not be attacked and killed by T cells. Immune checkpoint inhibitors block these proteins and the ability of T cells to kill cancer cells is increased. They are used to treat some patients with advanced malignant melanoma.
There are two types of immune checkpoint inhibitor therapy:
- CTLA-4 inhibitor therapy: CTLA-4 is a protein on the surface of T cells that helps keep the body's immune responses in check. When CTLA-4 attaches to another protein called B7 on a cancer cell, it stops the T cell from killing the cancer cell. CTLA-4 inhibitors attach to CTLA-4 and allow the T cells to kill cancer cells. Ipilimumab is a type of CTLA-4 inhibitor.
Immune checkpoint inhibitor. Checkpoint proteins, such as B7-1/B7-2 on antigen-presenting cells (APC) and CTLA-4 on T cells, help keep the body's immune responses in check. When the T-cell receptor (TCR) binds to antigen and major histocompatibility complex (MHC) proteins on the APC and CD28 binds to B7-1/B7-2 on the APC, the T cell can be activated. However, the binding of B7-1/B7-2 to CTLA-4 keeps the T cells in the inactive state so they are not able to kill tumor cells in the body (left panel). Blocking the binding of B7-1/B7-2 to CTLA-4 with an immune checkpoint inhibitor (anti-CTLA-4 antibody) allows the T cells to be active and to kill tumor cells (right panel). - PD-1 and PD-L1 inhibitor therapy: PD-1 is a protein on the surface of T cells that helps keep the body's immune responses in check. PD-L1 is a protein found on some types of cancer cells. When PD-1 attaches to PD-L1, it stops the T cell from killing the cancer cell. PD-1 and PD-L1 inhibitors keep PD-1 and PD-L1 proteins from attaching to each other. This allows the T cells to kill cancer cells. Nivolumab is a type of PD-1 inhibitor.
Immune checkpoint inhibitor. Checkpoint proteins, such as PD-L1 on tumor cells and PD-1 on T cells, help keep immune responses in check. The binding of PD-L1 to PD-1 keeps T cells from killing tumor cells in the body (left panel). Blocking the binding of PD-L1 to PD-1 with an immune checkpoint inhibitor (anti-PD-L1 or anti-PD-1) allows the T cells to kill tumor cells (right panel). immune checkpoint inhibitorsImmunotherapy uses the body's immune system to fight cancer. This animation explains one type of immunotherapy that uses immune checkpoint inhibitors to treat cancer. - CTLA-4 inhibitor therapy: CTLA-4 is a protein on the surface of T cells that helps keep the body's immune responses in check. When CTLA-4 attaches to another protein called B7 on a cancer cell, it stops the T cell from killing the cancer cell. CTLA-4 inhibitors attach to CTLA-4 and allow the T cells to kill cancer cells. Ipilimumab is a type of CTLA-4 inhibitor.
- Interferon: Interferon affects the division of cancer cells and can slow tumor growth. Gamma interferon is being studied in the treatment of recurrent malignant mesothelioma.
Targeted therapy
Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells.
Monoclonal antibody therapy is a type of targeted therapy. Monoclonal antibodies are immune system proteins made in the laboratory to treat many diseases, including cancer. As a cancer treatment, these antibodies can attach to a specific target on cancer cells or other cells that may help cancer cells grow. The antibodies are able to then kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells.
Bevacizumab is a monoclonal antibody used to treat advanced malignant mesothelioma. It binds to a protein called vascular endothelial growth factor (VEGF). This may prevent the growth of new blood vessels that tumors need to grow. Other monoclonal antibodies are being studied in malignant mesothelioma.
Kinase inhibitors are a type of targeted therapy being studied in the treatment of malignant mesothelioma. Kinase inhibitors are targeted therapy drugs that block signals needed for tumors to grow.
New types of treatment are being tested in clinical trials.
about clinical trials is available from the NCI website.
Treatment for malignant mesothelioma may cause side effects.
For information about side effects caused by treatment for cancer, see our Side Effects page.
Patients may want to think about taking part in a clinical trial.
For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.
Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.
Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.
Patients can enter clinical trials before, during, or after starting their cancer treatment.
Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.
Clinical trials are taking place in many parts of the country. Information about clinical trials supported by NCI can be found on NCI's clinical trials search webpage. Clinical trials supported by other organizations can be found on the ClinicalTrials.gov website.
Follow-up tests may be needed.
Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests.
Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.