Mesothelioma Clinical Trial

Chest pain and dyspnea are the most common symptoms of pleural mesothelioma. The chest pain is characteristically nonpleuritic and varies in intensity from mild to incapacitating. Constitutional symptoms such as fever, weight loss and weakness are not uncommon.

Despite the proven link between asbestos and mesothelioma, fewer than 50 percent of studied patients relate a definite history of asbestos exposure. This low figure may simply be a matter of inaccurate histories in persons with a disease that has a 20- to 50-year latency period or may reflect exposure to various dusts or chemicals presently unrecognized as etiologic factors, unrecognized incidental exposure or other etiologic mechanisms.

Physical findings are usually those of an underlying pleural effusion, which is present in more than 50 percent of cases at diagnosis. Other specific physical findings are usually lacking.

The tumor may spread through the thoracic wall, producing subcutaneous nodules, but distant metastasis is unusual at the time of initial diagnosis, and such a finding suggests another type of tumor. In about 25 percent of patients, hematogenous metastasis to other organs will develop during the course of the disease.

Chest radiographs are rarely normal in patients with mesothelioma. Findings include pleural effusion, pleural thickening, pericardial effusion, a mediastinal or chest wall mass, and pulmonary nodules.

Diagnosis is confirmed by tissue examination. In the presence of pleural effusion, about 30 percent of aspirated specimens of pleural fluid are positive for malignant cells. Pleural biopsy of the involved area is positive in about one-half of the cases and shows atypical cells in another one-third. If aspiration and needle biopsy of the pleura are negative, open thoracotomy with biopsy should be considered.

Patients with pleural mesothelioma require a multidisciplinary treatment approach, which may include surgery, radiation therapy and chemotherapy. Median survival is 12 months; only 5 percent of patients survive five years, although early diagnosis and treatment may occasionally lead to cure.

Aggressive combination therapy has been reported to prolong survival, but such studies did not address quality-of-life issues, and the findings have not been uniformly confirmed. The family physician's main task is usually to coordinate palliative therapy, assure pain control and provide psychologic support for patients and their families.

Illustrative Case

A 75-year-old man complained of constant upper-left lateral thoracic pain. He said he had fallen from his bicycle shortly before the onset of symptoms and attributed the pain to the fall. Physical examination was unrevealing. Rib films showed no abnormality, and he was treated with aspirin. When he was seen again one month later, the pain had not abated. His medication was changed to ibuprofen, again without total relief. A chest film at this time was normal.

For the next six months, the pain waxed and waned but was generally tolerable. The patient did not lose weight and, aside from weakness and mild dyspnea, did not complain of other symptoms.

When the pain suddenly worsened, another chest film was taken, which showed a pleural mass and effusion in the upper left thorax. At this point, the patient revealed that in 1937, he had been employed for 30 days as a lathe operator working on high-pressure pipes that contained asbestos. Pleural biopsy confirmed the diagnosis of mesothelioma.

Because of a recent myocardial infarction and worsening coronary artery disease, he was not a surgical candidate. Faced with the diagnosis, the patient entered a prolonged period of denial. A family conference was held, and the diagnosis, prognosis and practical options open to the patient were frankly discussed.

When the patient accepted the diagnosis and the inevitability of death, he executed a durable power of attorney for health care, completed a will and made other financial decisions important to his family. He chose not to undergo chemotherapy or radiation therapy.

The patient's care was managed at home with the assistance of visiting hospice nurses and family counseling. He died three and one-half months after the diagnosis of mesothelioma was made.

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