When treating patients with mesothelioma or pleural disease, Penn Medicine pleural specialists offer more treatment options than most other health systems across the country and around the world.
Penn Medicine's Mesothelioma and Pleural Program and Penn's Abramson Cancer Center in Philadelphia, PA bring together internationally renowned experts in medical, surgical and radiation oncology and pulmonology who collaborate in the diagnosis, treatment and research of mesothelioma and pleural disease.
Mesothelioma is a rare type of cancer that affects the lining of the chest or abdominal cavities. It is most often attributed to exposure to airborne asbestos particles and occurs in both men and women. Asbestos fibers are naturally occurring fibrous minerals that were commonly used in construction and thermal insulation as a fire retardant until the 1970s. Asbestos is still used in products, but regulations in place since the 1980s limit its use.
Air is breathed in through the nasal passageways, travels through the trachea and bronchi to the lungs.
Penn's multidisciplinary approach to cancer diagnosis and treatment provides better outcomes and gives patients access to the most advanced treatment, surgical techniques and clinical trials.
There is no guaranteed way to prevent mesothelioma or pleural disease. However, by avoiding asbestos exposure, people can significantly reduce their chances of developing these conditions.
Patients who feel they are at risk may benefit from consulting with a risk assessment specialist.
Risk factors affect a person's chance of getting mesothelioma or pleural disease. Having a risk factor, or even several, does not mean that someone will get cancer.
There are different kinds of risk factors. Some factors, like family history, can't be changed. Risk factors for mesothelioma and pleural disease include:
While there's no guaranteed way to prevent mesothelioma and pleural disease, there are steps people can take to reduce their risk of developing the disease.
The Cancer Risk Evaluation Programs at Penn Medicine offer knowledge about the presence of genetic risk factors for cancer and provide patients with important, sometimes life-saving options.
Patients at increased risk for mesothelioma or pleural disease may benefit from meeting with a cancer risk assessment counselor.
Mesothelioma is a rare type of cancer that affects the lining (mesothelium) of the chest (called the pleura) or abdomen (called the peritoneum). There are several different subtypes of mesothelioma, including epithelioid, sarcomatoid, biphasic and desmoplastic. Mesothelioma is most often attributed to exposure to airborne asbestos particles and occurs in both men and women. Asbestos is a group of naturally occurring fibrous minerals used as a fire retardant.
Symptoms of pleural mesothelioma include decreased appetite, weight loss, fatigue, shortness of breath and pain in the chest due to an accumulation of fluid in the pleura. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.
Treatment options for mesothelioma include chemotherapy, radiation therapy, surgery or participation in clinical trials testing new therapies.
There are several cancers that can spread to the pleural space. These cancers present a challenge for the health care team caring for these patients. Some of the cancers that have been known to spread to the pleura include: colon cancer, breast cancer, thymic cancer and sarcomas.
Treatment for these metastatic cancers can range from palliative care to aggressive multimodal treatments. The Penn Mesothelioma and Pleural Program specialists work closely with the oncologists at the Abramson Cancer Center in developing the most appropriate treatment plan for every individual.
While mesothelioma is the most common primary tumor of the pleural space, other tumors of the pleural space include:
Uncommon primary pleural neoplasms can mimic each other, as well as mimic metastatic cancers to the pleura and diffuse malignant mesothelioma. Correct diagnosis is important because of differing treatment options for the various tumors.
A pleural effusion occurs when the pleural fluid that lubricates the surfaces of the pleura builds up to abnormal, excessive amounts. Pleural effusions can be caused by congestive heart failure, pulmonary embolism, cirrhosis, cancer, infections, open-heart surgery, and physical trauma.
Symptoms of pleural effusion include:
Treatment for pleural effusion depends on the cause for the condition and can include chemotherapy or surgery. Management of a pleural effusion by drainage and/or chest tube placement is very important.
Pleurisy – also called pleuritis – occurs when the membrane (pleura) that lines the chest cavity and surrounds the lungs becomes inflamed. It can be related to a variety of underlying symptoms including asbestos-related disease, certain cancers, chest trauma, pulmonary embolus, and rheumatic disease.
The main symptom of pleurisy is sharp pain that occurs when inhaling and exhaling or coughing. Some people experience pain in the shoulder. When fluid collects in the chest cavity as a result of pleurisy, it can cause additional symptoms including shortness of breath, rapid breathing, coughing or bluish skin (cyanosis).
Relieving pleurisy involves treating the underlying problem, if known. Current treatment options include antibiotics, acetaminophen and anti-inflammatory drugs, and thoracentesis.
A pneumothorax, or collapsed lung, is the collection of air in the space around the lungs. This buildup of air puts pressure on the lung so it cannot expand as much as it would normally when breathing. A pneumothorax may be caused by chest trauma, rib fracture, certain medical procedures, select lung conditions and, in come cases, there may be no direct cause. Additionally, some activities such as scuba diving, smoking, and high-altitude biking and flying can cause a pneumothorax.
The symptoms of pneumothorax include sharp chest pain and shortness of breath. Large pneumothorax can cause chest tightness, easy fatigue, rapid heart rate, and bluish skin (cyanosis).
In less severe cases, the pneumothorax may go away with oxygen and rest. When the patient is experiencing a large pneumothorax, Penn surgeons place a chest tube between the ribs in the space around the lungs to help drain the air and allow the lung to re-expand. The tube may be left in place for several days and often requires hospitalization. In select cases, Penn surgeons operate on the patient to repair the leak.
A hemothorax is a collection of blood in the space between the chest wall and the lung as a result of chest trauma. Hemothorax can also be caused by a defect of blood clotting, pulmonary infarction, lung or pleural cancer, placement of a central venous catheter, thoracic or heart surgery, and tuberculosis.
Hemothorax is associated with:
A chest tube, inserted through the chest wall, is used to remove the blood and air in the pleural space. It remains in place for several days to re-expand the lung. When a hemothorax is severe, a thoracotomy may be needed to stop the bleeding.
Empyema is a collection of pus in the pleural space, caused by an infection that spreads from the lung and leads to a buildup of pus in the pleural space. Risk factors for empyema include bacterial pneumonia, lung abscess, previous thoracic surgery, or trauma or injury to the chest. Empyema can occur when a needle is inserted through the chest wall to draw fluid from the pleural space.
Symptoms of empyema include:
Treatment for this condition includes both systemic and local treatment.
Symptoms of pleural mesothelioma may include:
If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.
Symptoms of pleural effusion include:
The main symptom of pleurisy is sharp pain that occurs when inhaling and exhaling or with coughing. Some people experience pain in the shoulder. When fluid collects in the chest cavity as a result of pleurisy, it may cause additional symptoms including:
Sharp chest pain and shortness of breath are the main symptoms of a pneumothorax, or collapsed lung. Large pneumothorax can cause chest tightness, easy fatigue, rapid heart rate, and bluish skin (cyanosis).
There are several possible symptoms associated with a hemothorax including:
"Staging" is a system that provides doctors with a common language for describing tumors. After cancer is first diagnosed, a series of tests are used to investigate the extent of the cancer and to see whether it has spread to other parts of the body from where it started.
Staging is a way of recording the size and growth of a cancer, and determining the plan for treatment. Mesothelioma is broadly staged into two categories: localized (the tumor is restricted to the membrane surface where it originated) and advanced (the tumor has spread to neighboring structures and distant organs and tissues). By understanding the stage of their cancer, patients can make informed decisions about their treatment.
Staging mesothelioma attempts to discover the following:
Patients under the care of Penn's Mesothelioma and Pleural Program benefit from a multidisciplinary team of specialists who are committed to providing the most advanced treatment options available for these conditions. At Penn, patients and their families receive the support and education that they need to understand the diagnosis as well as the vast resources available to them through the health system.
In addition to the physician, the Penn Medicine Mesothelioma and Pleural Program's internationally recognized specialists are supported by an experienced and dedicated health care team that includes:
Research plays an important role within Penn's Mesothelioma and Pleural Program. When appropriate, patients are enrolled in clinical trials that help to improve current treatments or obtain information about new treatments.
At Penn, researchers are exploring ways to improve and expedite the diagnostic process through a greater understanding of mesothelioma's genetic links. They are also aggressively studying the use of photodynamic therapy and proton therapy – two technologies that are showing promise in the treatment of mesothelioma.
An accurate diagnosis is the key to providing patients with the high level of care that they require for mesothelioma or pleural disease. At Penn, specialists who have extensive experience diagnosing and treating these complex conditions employ the latest tests and tools to provide patients with a timely, accurate diagnosis.
Currently, there are no recommendations for screening for mesothelioma or pleural disease, like there are for breast or colon cancer. However, people who have been exposed to asbestos, or who are at an increased risk for mesothelioma and pleural disease, should speak with their physician about screening tests that may detect early signs of cancer.
Physicians at Penn Medicine also recommend that people who have been exposed to asbestos know the signs and symptoms of mesothelioma.
Mesothelioma can be difficult to diagnose because its symptoms can be similar to those of other diseases. Pleural specialists at Penn Medicine have significant experience with this disease and employ the most advanced, minimally invasive techniques to obtain an accurate diagnosis.
Diagnostic tools used by Penn’s Mesothelioma and Pleural Program include:
Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's chance of recovery.
Once a diagnosis of mesothelioma is confirmed, staging of the disease is the next step in determining potential treatment options. Mesothelioma staging requires knowledge about where the tumor is located, how extensive it is in that location, whether the tumor metastasized to organs or adjacent tissues, and if it has spread to lymph nodes. Non-invasive staging is determined by the results of CT and/or MRI of the chest/abdomen/pelvis, PET scans and brain scans.
Invasive staging studies include various surgical procedures:
The International Mesothelioma Interest Group and Brigham & Women's Hospital have developed staging systems based upon a set of disease characteristics, which include:
Based on each of these three characteristics in combination, the stage of the mesothelioma is determined and, from this stage, a treatment plan is developed. A brief summary of each stage is described below:
Stage I: Mesothelioma affects the pleural space on only one side of the body but has not yet spread to other organs or the lymph nodes.
Stage II: Mesothelioma has spread more extensively within the pleural space or even into the lung itself and may also have extended into the diaphragm but has still not reached the lymph nodes or distant sites.
Stage III: Mesothelioma may have spread to the lymph nodes near the tumor, but would not have spread as far as the collarbone. It may also have spread into the chest wall, or even into the outer layer covering the heart, but has not yet spread to the other side of the chest or to distant sites.
Stage IV: Mesothelioma may have spread into the chest wall muscle, the ribs, the trachea, the esophagus, the spine, to the other side of the chest, or into the heart itself. Mesothelioma is also classified at Stage IV if it affects lymph nodes near the collarbone or has spread to distant sites.
Penn Medicine's pleural specialists develop personalized treatment plans for patients with mesothelioma and pleural disease, designed to give every patient the best possible outcome. Penn's treatment options for mesothelioma and pleural disease include:
Patients who come to Penn Medicine for their cancer care benefit from coordinated care across disciplines and modalities. The expertise of Penn's Abramson Cancer Center in cancer diagnosis, treatment planning and integrated medicine, helps patients who come to Penn Mesothelioma and Pleural Program receive nationally recognized care that leads to better outcomes and improved quality of life.
Surgery is a valuable tool for treating mesothelioma and pleural disease. Penn Medicine's internationally recognized surgical experts collaborate closely with their colleagues in radiation and medical oncology to develop individualized treatment approaches for patients.
Treatment plans depend largely upon the location and stage of the tumor as well as the patients' overall health. In all cases, Penn's specialists strive for the safest and least invasive treatment options to preserve quality of life.
Surgeons remove the lung, pericardium (membrane covering the heart), part of the diaphragm (muscle between the lungs and abdomen), and part of the parietal pleura (membrane lining the chest) to treat malignant mesothelioma.
Patients with recurrent pleural effusion are sometimes treated with an indwelling pleural catheter. The device, inserted into the pleural space by Penn surgeons, removes excess fluid from the chest cavity and relieves symptoms associated with pleural effusion while allowing patients to remain at home.
Patients with mesothelioma may undergo a pleurectomy (removal of the lining around the lungs) or peritonectomy (removal of the membrane that lines the cavity of the abdomen) to remove diseased tissue. Penn surgeons combine this procedure with photodynamic therapy and are achieving promising results.
The goal of cytoreductive surgery, sometimes called “debulking” surgery, is to remove as much of a tumor as possible. It is commonly combined with radiation therapy or chemotherapy.
Pleural sclerosis is used to obliterate the pleural space in order to prevent the recurrence of a spontaneous pneumothorax or the reaccumulation of a pleural effusion. Many different agents, ranging from antibiotics to talc are used to eliminate the space in which air or fluid can accumulate.
This simple procedure drains the fluid and relieves the symptoms of pleural effusion. It may also be used as a diagnostic test to look for causes of a pleural effusion. During therapeutic thoracentesis, physicians insert a needle into the pleural space to remove the fluid, relieving the pressure on the lungs and making breathing easier.
Surgeons make an incision between the ribs on one side of the chest to remove all or part of a lung, avoiding the heart and spinal cord.
This minimally invasive technique is used to diagnose and treat problems in the chest. A tiny camera called a thoracoscope and surgical instruments are inserted in the chest through small incisions, and the thoracoscope transmits images to a video monitor, guiding the surgeon in performing the procedure. VATS can be used to perform a biopsy, to remove tumors or remove an entire lobe from the lung
Radiation therapy's ability to precisely target and attack diseased tissue – thereby slowing or stopping tumor growth – makes it an integral component of many treatment plans developed by Penn's Mesothelioma and Pleural Program. Penn Radiation Oncology offers patients the full complement of radiation treatments including proton therapy – a powerful tool available at only a few centers in the nation.
Brachytherapy involves placing small, radioactive implants, such as metal pellets, seeds, ribbons, wires, needles, capsules, or tubes in small, sealed holders inside the body. This is done in a hospital operating room and requires imaging technology (such as X-ray or MRI) to determine the exact location for the radiation to be placed to most effectively treat the cancer. Implants may be left in the body for only a short time, or permanently.
The advantage of brachytherapy is that it delivers a high dose of radiation to a smaller area than may be possible with external radiation treatment, which is delivered by machines located outside the body.
IMRT is a form of radiation therapy administered by a linear accelerator – a computer-controlled device that delivers precise doses of radiation to tumors or specific areas within the tumors. Because IMRT uses 3-D computed tomography (CT) images and computerized dose calculations, it can conform, or modulate, the radiation beam more precisely to the shape of the tumor. This helps ensure that exposure to healthy surrounding tissue is minimized.
Penn was the first health system in the Philadelphia region to use PDT to treat pleural cancers. Also known as photoradiation therapy, phototherapy, or photochemotherapy, PDT brings together light-sensitive medication (photosensitizer) and low-level beams of light to destroy cancer cells. Photosensitizers are drugs that, when exposed to a specific wavelength of light, produce a form of oxygen that kills nearby cells. PDT can also shrink or destroy tumors by damaging the blood vessels that feed them, depriving the tumor of nutrients. Additionally, PDT may activate the immune system to attack the tumor cells. Intraoperative photodynamic therapy is combined with radical pleurectomy for treating pleural malignancies.
Penn Medicine's Roberts Proton Therapy Center is the largest and most sophisticated facility in the world for this advanced form of radiation treatment. Proton therapy is external beam radiotherapy in which protons are directed at a tumor. The radiation dose that is given through protons is very precise, and limits the exposure of normal tissues. This allows the radiation dose delivered to the tumor to be increased beyond conventional radiation. The result is a better chance for curing cancer with fewer harmful side effects.
Proton therapy, like all forms of radiation therapy, works by aiming the energized particles — in this case protons — onto the target tumor. The particles damage the DNA of cells, ultimately causing their death. Unlike X-rays, protons can be manipulated to release most of their energy only when they reach their target. With more energy reaching the cancerous cells, more damage is administered by each burst of radiation.
VMAT radiation beams sweep in uninterrupted arc(s) around the patient, speeding treatment delivery and reducing treatment time. Imaging increases the precision and allows physicians to visualize the tumor target at the time of treatment and to guide therapy that both maximizes the radiation dose to the target and minimizes exposure to surrounding healthy tissues.
Penn Medicine specializes in a team approach to treatment with interdisciplinary care and innovative approaches that use chemotherapy to target tumors prior to and after surgery.
Medical oncologists at Penn's Abramson Cancer Center are experts in treating cancer with chemotherapy and other adjuvant approaches. They lead the way in developing new targeted therapies such as the use of monoclonal antibodies, vaccines and immune-based therapies.
Adjuvant therapy is treatment given after surgery. It is often used in combination with other forms of cancer treatment to reduce the chance of recurrence. These therapies may include chemotherapy, hormone therapy, targeted therapy, immunotherapy (biologic therapy) or vaccine therapy.
Chemotherapy uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy is taken by mouth or injected into a vein or muscle, depending on the type and stage of the cancer being treated. The drugs enter the bloodstream and can reach cancer cells throughout the body. Multiple drugs that attack cancer in different ways can be combined to increase their effectiveness.
Researchers at Penn Medicine are pioneering the use of two forms of gene therapy for treating mesothelioma. In the first, a new gene is placed in a modified cold virus and inserted into the tumor itself. This new gene makes a substance called interferon that causes the body to reject the tumor using its own immune system.
In the second approach, patients' own white blood cells are collected and modified to recognize the tumor. When injected back into the patient, they attack and kill the tumor.
Immunotherapy uses patients' own immune systems to fight cancer. Penn medical oncologists use biologic or synthetic agents to repair, stimulate or enhance the immune system, triggering the body's natural defenses to eliminate the cancer cells.
At Penn, medical oncologists sometimes use targeted therapies, such as drugs or other substances to block the growth and spread of cancer by interfering with specific molecules involved in tumor growth and progression.
Endobronchial ultrasound-guided biopsy is a non-surgical method for detecting mediastinal lymph node metastases in early-stage lung cancer. The bronchoscopic technique uses ultrasound to visualize the structures within and adjacent to the airway wall while using a fine needle to remove cells for examination.
A treatment for severe recurrent pleural effusion, a pleuroscope is used to inspect the pleura and take biopsies of suspicious areas. The space between the pleura is then coated with medication to prevent the reaccumulation of fluid.
Today, more and more people are surviving cancer. Clinical trials benefit patients with access to breakthrough therapies and treatments. These new advances in cancer treatment are occurring every day at Penn Medicine, giving patients hope that even greater discoveries lie ahead.
Through clinical trials:
At Penn, members of the Mesothelioma and Pleural Disease program are:
In all cases, research is focused on enhancing and extending the quality of life with the ultimate goal of curing cancer.
In addition to standard treatments and clinical trials, patients at Penn Medicine may wish to add other therapies and treatments such as massage therapy, acupuncture and art therapy. These therapies do not have curative intent, and are designed to complement standard treatments, not take their place.
At Penn Medicine, integrative medicine and wellness services can supplement traditional cancer treatments such as chemotherapy, surgery and radiation therapy. While conventional medicine plays a critical role in eradicating cancer, integrative medicine and wellness programs offer patients and their families ways to enhance the quality of their lives, minimize or reduce the side effects of cancer and cancer treatment, and promote healing and recovery.
The physicians at Penn Medicine are knowledgeable and supportive of complementary cancer treatments. The cancer team works with patients and families to integrate these supportive programs into the overall care plan, while ensuring the safety and health of patients.
The Abramson Cancer Center's range of integrative supportive services is designed to help patients cope with the cancer experience and improve their overall sense of well-being. Services include:
The Abramson Cancer Center at Pennsylvania Hospital offers a variety of supportive care programs for patients and families, from diagnosis through survivorship. These programs are available at no cost to the patients treated at Pennsylvania Hospital, and some are open to patients treated elsewhere. These services include social work counseling, nutrition counseling, psychological counseling and spiritual counseling.
The Cancer Appetite and Rehabilitation Clinic focuses on patients with loss of appetite and weight, as well as the weight loss, muscle atrophy, fatigue and weakness that can accompany cancer treatment.
The Supportive Care Clinic helps to manage cancer related symptoms. Integrative support programs include:
Support groups and educational programs are available at Pennsylvania Hospital throughout the year.
Palliative care provides medical and non-medical interventions to ease the symptoms of cancer and its treatment. Palliative care includes physical, emotional and spiritual care that can enhance the quality of life for cancer patients.
Palliative care can be used to complement traditional cancer therapies, or can be used when curative therapies are no longer an option to treat symptoms and improve quality of life.
Palliative care is an approach to patient care that can be integrated with curative therapies at any point from diagnosis to survivorship or end-of-life care.
Palliative care services include palliative chemotherapy, radiation therapy and surgery as well as psychological counseling, art therapy and support groups for patients and families. The goals of palliative care are to enhance the quality of life for cancer patients and their families, and provide emotional and spiritual support to enhance personal growth.
Penn Home Care and Hospice Services offer a full range of home health care needs by partnering three top-level home health care services under one roof:
At Penn Medicine, significant research in the diagnosis and treatment of mesothelioma and pleural disease is giving patients with these conditions new hope for long-term survival.
To meet patients' varied physical, emotional and financial needs, Penn's robust network of navigation specialists includes social workers, stress management specialists, alternative medicine practitioners and clergy. Additionally, the support groups and survivorship programs at Penn provide patients and their families with a valuable network that serves to enhance and extend the quality of life following a cancer diagnosis.
At the end of treatment, mesothelioma and pleural disease patients should schedule a survivorship visit with their oncologist and nurse practitioner. At this time, patients are provided with a summary of the treatment received as well as a plan for follow-up care.
Penn cancer providers work one-on-one with patients to develop survivorship care plans. Since every cancer is unique, the plans are tailored to the patients.
The survivorship care plan includes information on:
A survivorship care plan encourages patients to review the information with their health care team and become active participants in their follow-up care.
Penn also offers patients a number of support programs and groups to enhance their survivorship care plans.
Penn Medicine’s Living Well After Cancer™ Program is a nationally recognized program that focuses on issues facing cancer survivors. A member of the LIVESTRONG™ Survivorship Center of Excellence Network, the Abramson Cancer Center focuses on survivorship, a distinct phase of care.
Prescription for Living: The Cancer Survivorship Program at the Abramson Cancer Center at Pennsylvania Hospital provides patients with a summary of important information about specific cancer diagnoses and treatments, as well as follow-up information and steps to take towards recovery, supportive care and education to help patients adjust to their lives as cancer survivors.
Penn offers cancer patients support programs and groups to enhance their survivorship care plans.
The Abramson Cancer Center and Abramson Cancer Center at Pennsylvania Hospital offer a wide range of materials and host many activities that provide education and support to address key areas of concern including survivorship for cancer patients and their loved ones.
Focus On: Mesothelioma is a day-long conference for patients and their loved ones addressing issues surrounding mesothelioma and pleural disease.
In 2003 her doctors found a cancerous brain tumor, estimating that she had a year and a half to live. Sallie Nangeroni wanted the best neurosurgeon in the region. She came to HUP. Sally was rightfully scared. Her father died of brain cancer when he was just 40 years old, and her husband's brother had just passed away from a brain tumor. At the time she was diagnosed, Sallie just hoped that she would be able to see all three of her sons graduate from high school. Now, 7 years later, she has seen two of them graduate from college, with one now in medical school. Her next goal is to see her youngest son graduate from college next year.
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