Description: Diffuse Malignant Pleural Mesothelioma is uncommon, yet aggressive type of cancer that mainly arises from the mesothelial cells that make up the lining of pleural. It remains to be a critical tumour that is hard to diagnose and treat and this result in progression of tumour and decreased chances of effective multimodality regimes.
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Diffuse Malignant Pleural Mesothelioma or DMPM is the aggressive type of cancer with gloomy prognosis and it is largely been associated with exposure to industrial grade asbestos. It is a disease of industrialised nations mainly and it is expected to reach its zenith by the end of 2020. The difficulties in staging, diagnosing and treatment make this disease stand apart from other malignancies. The multimodality regimes including the radiation therapy, surgery and chemotherapy are known to enhance the life expectancy of the patients, but these treatment options can’t treat the disease permanently and kill cancer to help patients lead a healthy life ahead. The multimodality regimes only focus on alleviating the pain and agony associated with the disease, while increasing the survival rate in selected patients. Although asbestos exposure remains the primary epidemiologic factor for Diffuse Malignant Pleural Mesothelioma, but recently it is also recognised that simian virus 40 also plays the active role in causing such diseases in patients.
Management of Diffuse Malignant Pleural Mesothelioma seems very challenging for doctors as its staging, diagnosis and treatment are hard to recognise in the early stage. Due to poor randomised studies and researches and very low incidence of such tumour are primarily liable for absence of an accord on how to manage and treat the condition aptly.
Standard Radiology Evaluation of Diffuse Malignant Pleural Mesothelioma
The standard radiological evaluation for Diffuse Malignant Pleural Mesothelioma includes computed tomography Scan of the chest, chest x-ray, MRI or magnetic resonance imaging. Pleural plaques, effusions and thickening around the lining of the mesothelial can easily be discovered with plain chest x-rays. But respectability can only be discovered with MRI as it is performed to assess the extent of invasion into the mediastinum, chest wall and diaphragm. CT Scan and MRI scan can offer the doctors with more precision report and helps them to determine the resectability.
Fluorodeoxyglucose positron emission tomography or PET test is performed with enhanced frequency to assess the distant occult disease. This test is performed to detect the presence of other distant diseases if the CT scan test fails to detect the presence of distant disease. Two-Dimensional echocardiography is another helpful test that can help doctors to detect the resectability. This test is based on an assessment of cardiac functions and pericardial involvement.
The Staging Systems for Diffuse Malignant Pleural Mesothelioma
There are diverse staging systems are proposed for the Diffuse Malignant Pleural Mesothelioma, unfortunately, none of the staging systems has widely accepted. The staging system has been designed to stratify the survival of patients and administer therapy and treatments. Two Tumour/Node/Metastasis or TNM System was proposed, but still, these staging systems need to be evaluated and validated.
Treatment for Diffuse Malignant Pleural Mesothelioma
- Single Modality Therapy – The single modality therapy, irrespective of the type, has always failed to increase the survival of the patients. The two main surgeries that are included in this therapy for cytoreduction of malignant Pleural Mesothelioma are extrapleural pneumonectomy and decortications/pleurectomy. Till now, there is no randomised trial that can be used to compare these to procedures and hence there is still a debate going on amongst medical professionals to find out which procedure is appreciated for treating the disease and increase survival.
- Multimodality Therapy – The multimodality therapy is mainly developed in a bid to enhance the survival results amongst the patients. The primary protocol of multimodality therapy is to offer surgical cytoreduction in conjunction with chemotherapy, adjuvant radiation therapy or both. It is found that adjuvant therapies are very effective when maximised cytoreduction is achieved, thereby the need of penetration in entire pleural with chemotherapeutic agents can be reduced and more focal areas can be targeted with radiotherapy. The surgical procedures performed under single modality therapy can be included with multimodality protocols for more effective results.
Modern Treatment Approaches for Diffuse Malignant Pleural Mesothelioma
It has been found that subset of patients with Pleural Mesothelioma can benefit from the multimodality therapies and extrapleural pneumonectomy. However, patients with advanced stage of Diffuse Malignant Pleural Mesothelioma are required to undergo other treatment options that can’t achieve the significant increase in survival with the multimodality approaches. Some of the other modern treatment approaches are mentioned below.
- Photodynamic Therapy – This therapy is offered following decortications/pleurectomy or extrapleural pneumonectomy with erratic success. However, this therapy is only beneficial for patients with the early stage of the disease, but no improvement in survival has been seen in patients with the advanced stage of Pleural Mesothelioma. Introducing new photosensitizing agents and increasing the depth of penetration and using advanced techniques of light delivery can guarantee more effective results with this therapy.
- Immunotherapy – This is a therapy that involves the utilisation of cytokines to improve the immune system and antitumor response in the body of the patients. The tumour of Pleural Mesothelioma can release compounds like transforming growth factor, insulin-like growth factor, interleukin, platelet-derived growth factors A and B. The TGF-beta is clinically approved to hamper the propagation of cells with antitumor activity and hence it acts as natural cancer cell killer.
- Gene Therapy – The gene therapy basically involves using of viruses to chance the genetic materials in the body of patients either in immune cells or tumour cells so as to change the biological activity and increase the survival rate of the patients. The most common virus used in gene therapy includes adenoviruses.
These were some of the modern therapy and treatment options that are performed in hospitals to treat the patients of Pleural Mesothelioma. All these treatment options are mainly offered to patients with advanced stage of Diffuse Malignant Pleural Mesothelioma. The purpose of these treatments is to increase the survival of the patients and reduce the pain associated with the disease.