Written By: Devin Golden
Pleural Mesothelioma
Pleural mesothelioma is a cancer of the lung’s lining, known as the pleura. It is caused by inhaling asbestos fibers into the lungs. The best treatment option for survival is surgery. If surgery isn’t an option, most patients receive either chemotherapy, immunotherapy or a tumor treating fields device.
Medically Reviewed By
Dr. Abraham Lebenthal
Mesothelioma Thoracic Surgeon
Medically Reviewed By
Dr. Abraham Lebenthal
Mesothelioma Thoracic Surgeon
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Important Facts About Pleural Mesothelioma
- Around 75-80% of mesothelioma cases are pleural mesothelioma.
- Around 80% of pleural mesothelioma patients are male.
- Treatment options include surgery, chemotherapy, radiation, immunotherapy and tumor treating fields.
- Survival is usually 1-2 years depending on the stage, patient’s age and health, and the treatments used. Some patients survive much longer, and the 5-year survival rate is 10% and rising as treatment improves.
- More patients are getting treatment, which is improving survival rates from pleural mesothelioma. Nearly 50% live for at least one year.
What Is Pleural Mesothelioma?
Pleural mesothelioma is a cancer of the pleural cavity, which is a thin membrane between the chest wall and lung cavity. This specific disease makes up approximately 80% of all mesothelioma cases.
Malignant pleural mesothelioma means it is cancerous and can spread. The average life expectancy of a patient is 11-20 months. Some patients have lived for multiple years due to evolving surgical techniques.
Pleural Mesothelioma Causes
The only known cause of pleural mesothelioma is exposure to asbestos fibers. Asbestos products are usually found in homes and businesses built prior to the 1980s. Occupational asbestos exposure is the most common cause of mesothelioma.
When asbestos fibers are inhaled, they often travel to the lungs. However, these fibers sometimes enter the pleural space, which includes mesothelial cells. Fibers irritate cells and cause mutations.
While these cells often absorb unwanted particles, they struggle to expel asbestos fibers. The irritable substance can cause the mesothelial cells in the pleura to mutate. This leads to clumps of cells, also called tumors.
How Is Pleural Mesothelioma Treated?
Surgery
There are two primary surgical options for malignant pleural mesothelioma patients: extrapleural pneumonectomy and pleurectomy with decortication. The former removes the affected lung while the latter preserves this organ.
Chemotherapy
The chemotherapy drugs approved by the U.S. Food and Drug Administration (FDA) for malignant pleural mesothelioma are pemetrexed and cisplatin. Chemotherapy is often used in combination with other treatment options.
Immunotherapy
The FDA approved Opdivo and Yervoy for pleural mesothelioma. These two drugs are immunotherapies. They are available to patients who cannot have surgery for their cancer. Other types of immunotherapy are in clinical testing.
Radiation
Scientists are developing radiation techniques to target tumors and leave healthy tissue unharmed. Radiation is also used for palliative purposes.
Tumor Treating Fields
Tumor treating fields send electromagnetic waves through the body to disrupt cancer cell growth. The FDA approved a tumor treating fields device, called Optune Lua, in 2019 for malignant mesothelioma. The therapy is for patients who cannot have surgery.
Pleural Mesothelioma Symptoms
Pleural mesothelioma patients may experience symptoms like fever, shortness of breath and persistent coughing. These symptoms are common for other diseases, such as pneumonia.
Other pleural mesothelioma symptoms include:
- Pain in the lower back or chest
- Shortness of breath
- Unexplained weight loss
- Swelling of the face or arms
- Fluid buildup in the pleural space
- Sweating
- Hoarseness
- Trouble swallowing
Explaining Early Signs of Pleural Mesothelioma
One of the toughest parts of fighting pleural mesothelioma is detecting the rare cancer. Early detection is important but also challenging. Not many know the symptoms of mesothelioma, and some disregard them as more common health issues.
There are a few early signs of pleural mesothelioma. If you react quickly and get diagnosed soon enough, you may be eligible for surgery and save your life.
Pleural Effusions
Pleural effusions are buildup of fluid in the pleural space. This area is where pleural mesothelioma forms. It’s a narrow lining of tissue and fluid. When tumors form, they take up the already-limited space and push fluid into pockets.
Doctors can notice pleural effusions on imaging scans, such as an X-ray or computed tomography (CT) scan.
Pleural effusions are the first diagnostic sign of pleural mesothelioma. A report in ScienceDirect found 60% of diagnosed cases had this symptom.
Pleural Thickening
Pleural thickening occurs when scar tissue plaques form in the pleura. This scar tissue is the result of asbestos fibers sharply penetrating the mesothelial cell lining.
Pleural mesothelioma forms within this scar tissue, which causes an inflammation of tissue. This sign is also detected through X-ray or CT scans. The ScienceDirect report found pleural thickening in 88% of diagnosed cases.
Pleural Mesothelioma Diagnosis
The first step in diagnosing pleural mesothelioma is imaging tests, such as an X-ray or a computed tomography (CT) scan. If the test results show possible cancerous tumors, doctors likely will perform a biopsy.
A biopsy involves taking a small tissue sample to test for cancer cells. A biopsy also helps doctors determine the cell histology and possibly the stage of the disease (if the biopsy is of a lymph node).
Doctors may also extract a fluid sample to look for cancerous cells. However, this method is less reliable than a tissue biopsy.
Who Gets Pleural Mesothelioma?
According to the American Society of Clinical Oncology, the median age of pleural mesothelioma patients is 72. This is at the time of their diagnosis.
The disease’s latency period — meaning how long it takes to develop — is 20-50 years. This lengthy development time is why many patients are elderly.
According to another study, around 80% of patients are male. This is largely due to occupational exposure to asbestos.
Can Pleural Mesothelioma Spread to Other Organs?
Malignant pleural mesothelioma can spread to the lymph nodes, which can cause cancer to spread throughout the body more quickly. The disease also spreads to the nearby lung, heart and diaphragm.
The 4 Stages of Pleural Mesothelioma
Stage 1 - Tumors are only in the pleural cavity, which is the disease’s point of origin. The cancer likely just developed and has not had enough time to spread to other tissue. Detection at this stage is difficult.
Stage 2 - The cancer is mostly limited to the point of origin, but some localized lymph node involvement begins. Tumors may begin spreading into the lung cavity.
Stage 3 - The disease is no longer localized, metastasizing to the nearby lung, the diaphragm and more lymph nodes.
Stage 4 - The cancer has spread to nearby structures like heat, major vessels, spine or contralateral pleural space. The cancer has also spread to at least one distant area. Many treatment options are unavailable at this stage.
Surgery for Pleural Mesothelioma
Pleural mesothelioma surgery is a common treatment option and is often considered the best method to increase survival. There are two surgery options available to treatment pleural mesothelioma: extrapleural pneumonectomy (EPP) and pleurectomy with decortication (P/D).
Extrapleural Pneumonectomy (EPP)
Extrapleural pneumonectomy is a common surgical treatment for malignant pleural mesothelioma. During EPP, surgeons remove the diseased lung. They also remove the pleura, part or all of the diaphragm, and part or all of the pericardium.
The goal of EPP is to remove as much, if not all, of the cancer as possible. Mesothelioma tumors are microscopic, which is why removing the entire cancer is challenging for surgeons.
Patients can undergo chemotherapy following their operation. Using chemotherapy after surgery is called adjuvant cancer treatment.
Chemotherapy may also be used as a pre-surgery precaution to shrink the tumors beforehand. Using chemotherapy before surgery is called neoadjuvant treatment.
Dr. David Sugarbaker perfected EPP. Until his death in 2018, he was one of the leading mesothelioma specialists in the country.
Pleurectomy With Decortication (P/D)
Pleurectomy with decortication is an alternative to EPP. It was developed for malignant pleural mesothelioma when EPP is deemed too risky.
P/D is most effective for early-stage pleural mesothelioma patients. The surgery spares their lungs and only takes out the pleura, where most of the cancer is located.
Some patients may need their pericardium and part of their diaphragm taken out during P/D. This surgery is called an “extended pleurectomy with decortication.” It’s effective when the cancer has spread beyond the pleural space.
Patients may also undergo chemotherapy before or after P/D.
Chemotherapy for Pleural Mesothelioma
Chemotherapy for pleural mesothelioma is another common treatment method for patients with this type of cancer. Chemotherapy can be administered before, after or during surgery, as an alternative to surgery or in combination with other therapies.
Pemetrexed and cisplatin are the two FDA-approved chemotherapy drugs or treating malignant pleural mesothelioma. These drugs are often administered intravenously.
Another option is hyperthermic intrathoracic chemotherapy. This involves hot chemotherapy drugs delivered directly into the lung cavity.
Immunotherapy for Pleural Mesothelioma
Immunotherapy for pleural mesothelioma is the newest FDA-approved treatment for this type of cancer.
Opdivo and Yervoy are immune checkpoint inhibitor drugs, a type of immunotherapy drug for specific types of cancer, for malignant pleural mesothelioma. Immune checkpoint inhibitors help against pleural mesothelioma due to blocking cancerous proteins that subdue the immune system.
Opdivo and Yervoy block PD-L1 and B7 from latching onto PD-1 and CTLA-4, respectively. Another immunotherapy drug, Keytruda (pembrolizumab), is approved for cases with a high tumor burden volume. This immune checkpoint inhibitor also blocks PD-L1.
Opdivo and Yervoy have impressive survival rates. The combination led to an average survival of 18-19 months in large-scale mesothelioma studies. This outperforms chemotherapy by 4-5 months.
Radiation for Pleural Mesothelioma
Radiation is rarely curative for people with mesothelioma. This therapy may be used before or after surgery to shrink the size of tumors or reduce the chance of recurrence.
Doctors may also use radiation to ease pain caused by fluid buildup or tumor pressure. This therapy can shrink tumors, which should alleviate pressure in the chest.
Doctors may also use intraoperative radiation therapy. It’s best used with P/D. Doctors send radiation directly through the incision and into the chest cavity.
Mesothelioma specialists can provide their patients with a specialized treatment plan. If you are a mesothelioma patient, you can find a specialist by using our free Doctor Match program.
Tumor Treating Fields for Pleural Mesothelioma
The FDA approved a pleural mesothelioma tumor treating fields device called Optune Lua in 2019 under a Humanitarian Device Exemption ruling. It was originally called NovoTTF-100L System.
The device is for non-surgical cases of malignant pleural mesothelioma. It must be used in tandem with intravenous chemotherapy drugs pemetrexed and cisplatin (or carboplatin if needed).
The device sends electric fields into the patient’s chest region where the cancer is located. These waves disrupt the growth and division of cancer cells in the pleura and around the lungs.
The Optune Lua device is non-invasive and can be used while patients sleep. It’s only approved when surgery isn’t an option for treatment, and it must be used with chemotherapy. Nearly 100% of patients in a study had a positive response to the therapy. The survival stats outperform chemotherapy on its own.
Pleural Mesothelioma Prognosis
Pleural mesothelioma prognosis is an estimate of a particular patient’s life expectancy. It’s partly based on the experience of past patients.
Many factors play a role in a patient’s pleural mesothelioma prognosis:
- Cell type
- Stage of cancer
- Age
- Overall health
- Treatments
Since surgery directly removes tumors, this treatment option is considered the most effective at improving life expectancy. However, some patients cannot undergo surgery due to numerous factors, and undergoing an operation could lead to additional health concerns.
Approximately 40% of malignant pleural mesothelioma patients live for at least one year following their diagnosis. Patients who undergo P/D can live for multiple years.
One study published in the Annals of Thoracic Surgery reported half of patients living for three years after P/D.
The most effective way to improve your prognosis is starting treatment immediately. If you were diagnosed with this form of mesothelioma, then you should receive a second opinion from a specialist. You may learn your disease is at an earlier stage than you originally were told, and you could have more treatment options available.
Veterans With Pleural Mesothelioma
The largest group (around 33%) of people diagnosed with mesothelioma is military veterans. Asbestos was an insulant in military vehicles, naval vessels and army bunkers. The mineral was so widely used in the military that avoiding airborne asbestos fibers was close to impossible.
Due to the high prevalence of veteran mesothelioma patients, the U.S. Department of Veterans Affairs (VA) provides financial benefits to victims. Veterans who have this cancer can:
- Receive disability benefits, if their disease is service-related
- Find a specialist within the VA health care system
- Receive pension if their mesothelioma is not service-related
- Set up their surviving loved ones to receive benefits if they die from mesothelioma
Learn more about what veterans can do to support their families and live longer in our free Veteran’s Support Guide.
Frequently Asked Questions About Pleural Mesothelioma
How long do pleural mesothelioma patients live?
Pleural mesothelioma patients usually live a little less than one year after their diagnosis. A combination of surgery, chemotherapy and radiation can extend survival to multiple years.
What are the symptoms of pleural mesothelioma?
The symptoms of pleural mesothelioma include shortness of breath, fever, fluid buildup in the pleura, chest and lower back pain, sweating, trouble swallowing, weight loss, and swelling of the face or arms.
Is pleural mesothelioma curable?
Pleural mesothelioma is not curable, but there is hope for patients. Doctors are investigating new treatment methods in hopes of finding a permanent cure.
What causes pleural mesothelioma?
Exposure to asbestos is the only proven cause of pleural mesothelioma. If it’s swallowed or inhaled, asbestos can irritate cells in the pleura, which is the thin membrane between the lung cavity and chest wall.
How is pleural mesothelioma treated?
Pleural mesothelioma is usually treated with a combination of surgery, chemotherapy and radiation.
Sources & Author
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- Life Expectancy in Pleural and Peritoneal Mesothelioma. Lung Cancer International. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5292397/. Accessed: 03/19/19.
- Presentation, initial evaluation, and prognosis of malignant pleural mesothelioma. UpToDate. Retrieved from: https://www.uptodate.com/contents/presentation-initial-evaluation-and-prognosis-of-malignant-pleural-mesothelioma?topicRef=4625&source=see_link. Accessed: 03/19/19.
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- Signs and Symptoms of Mesothelioma. American Cancer Society. Retrieved from: https://www.cancer.net/cancer-types/mesothelioma/statistics. Accessed: 03/19/19.
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- Veterans Asbestos Exposure. U.S. Department of Veterans Affairs. Retrieved from: https://www.va.gov/disability/eligibility/hazardous-materials-exposure/asbestos/. Accessed: 04/20/2023.
- Debunking The Myths About Mesothelioma Procedure Pleurectomy and Decortication. Pacific Heart, Lung and Blood Institute. Retrieved from: https://www.cancer.org/cancer/malignant-mesothelioma/detection-diagnosis-staging/how-diagnosed.html. Accessed: 05/02/19.
- Extended pleurectomy decortication: the current role. Translational Lung Cancer Research. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6204414/. Accessed: 08/27/19.
- Extended Pleurectomy-Decortication–Based Treatment for Advanced Stage Epithelial Mesothelioma Yielding a Median Survival of Nearly Three Years. The Annals of Thoracic Surgery. Retrieved from: https://www.annalsthoracicsurgery.org/article/S0003-4975(16)31139-0/fulltext. Accessed: 08/26/19.
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