Epithelioid Mesothelioma Treatment

Epithelioid Mesothelioma Treatment Options

Epithelioid mesothelioma treatment options vary depending on the patient’s stage of cancer and type of mesothelioma. Patients are diagnosed with a type of mesothelioma, such as pleural mesothelioma or peritoneal mesothelioma, then diagnosed with a mesothelioma cell type, such as epithelioid. A patient’s epithelioid mesothelioma diagnosis helps specialists determine the best treatment plan.

The most common treatment options for epithelioid mesothelioma are surgery, chemotherapy, immunotherapy and radiation. Each of these treatment options is dependent on the type of mesothelioma.

There are three surgery options for epithelioid mesothelioma treatment: extrapleural pneumonectomy (EPP), pleurectomy with decortication (P/D) and cytoreductive surgery with HIPEC.

Extrapleural pneumonectomy (EPP) and pleurectomy with decortication (P/D) are epithelioid pleural mesothelioma surgical options, while cytoreductive surgery with HIPEC is an epithelioid peritoneal mesothelioma surgery. 

A patient’s surgery eligibility depends on the stage of cancer and the patient’s overall health status. If the cancer has spread throughout the body and affects vital organs, mesothelioma specialists may deem surgery too risky and opt for other treatment options instead. 

Pleural Epithelioid Mesothelioma Surgical Options

Epithelioid pleural mesothelioma surgical options include extrapleural pneumonectomy (EPP) and pleurectomy with decortication (P/D). These procedures focus on removing the pleura, where pleural mesothelioma forms. Removing the pleura is an effective way to remove the most mesothelioma tumors and diseased tissue as possible. 

Extrapleural pneumonectomy (EPP) is considered the most aggressive type of pleural epithelioid mesothelioma surgery. During EPP, the surgeons will remove the affected lung, the pleura, and potentially the pericardium (sac around the heart) and part of the diaphragm.

Pleurectomy with decortication (P/D) is an alternative surgery to EPP. It is less aggressive as it does not remove the lung. During P/D, surgeons will remove the pleura and, if needed, the pericardium and part of the diaphragm.

Peritoneal Epithelioid Mesothelioma Surgical Options

The only surgery for epithelioid peritoneal mesothelioma is cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). This is a two-part procedure; the first part is cytoreductive or debulking. Cytoreduction is a surgical procedure to remove as many mesothelioma tumors as possible by resecting the peritoneum, where peritoneal mesothelioma forms, and potentially part of the intestines or other affected abdominal organs and tissues.

The second part of cytoreduction with HIPEC is the administration of heated intraperitoneal chemotherapy. HIPEC is a heated, sterilized chemotherapy treatment that targets any remaining mesothelioma cells after surgery. Next, doctors will rock the patient back and forth to ensure the entire abdominal cavity is bathed in the chemotherapy drug solution.

Chemotherapy is a common treatment method for epithelioid mesothelioma. It targets mesothelial cells that divide and grow faster than normal. Traditionally, chemotherapy drugs are administered through an IV drip into the bloodstream, traveling to areas of rapid cell growth. The drugs stop these cells from replicating, which causes them to die.

There are different types of chemotherapy for epithelioid mesothelioma: systemic (intravenous) chemotherapy and heated intraoperative chemotherapy. Systemic chemotherapy is the most common type, while heated intraoperative chemotherapy is performed during surgery.

Epithelioid Pleural Mesothelioma Chemotherapy 

Chemotherapy for epithelioid pleural mesothelioma was approved by the FDA in 2004.

Pemetrexed and cisplatin are the two most commonly used chemotherapy drugs for epithelioid pleural mesothelioma treatment. They are approved for systemic administration through an IV.

Hyperthermic intrathoracic chemotherapy (HITHOC) for epithelioid pleural mesothelioma is an example of intrathoracic chemotherapy. It’s a type of heated chemotherapy where mesothelioma specialists deliver a mixture of heated chemotherapy drugs directly to the thoracic cavity during surgery. The tubing placed into the chest cavity gives the chemotherapy drugs direct access to the tumors and affected tissues.

The goal is to fill the chest cavity with heated chemotherapy drugs to kill any remaining mesothelioma cells and tumors after surgery. This direct delivery method reduces the amount of chemotherapy entering the bloodstream and traveling to other parts of the body. By containing most of the chemotherapy in the chest cavity, specialists minimize the risk of the chemotherapy drugs damaging healthy tissue or blood cells.

Epithelioid Peritoneal Mesothelioma Chemotherapy

Systemic chemotherapy is used by mesothelioma specialists for epithelioid peritoneal mesothelioma. This may be recommended before surgery, after surgery or as a stand-alone treatment for patients who aren’t eligible for surgery.

Cytoreductive surgery with heated intraperitoneal chemotherapy (HIPEC) is the primary epithelioid peritoneal mesothelioma treatment method. After surgeons have completed the cytoreduction portion of the procedure, they will administer HIPEC, an intraoperative treatment that targets remaining mesothelioma tumors after surgery. HIPEC delivers chemotherapy drugs directly into the abdominal cavity via catheter insertion into the abdomen.

The chemotherapy solution is pumped into the abdominal cavity and circulated throughout the abdomen for one to two hours. Once this process is complete, the medical team drains the chemotherapy fluid and rinses the abdominal cavity with sterile saline.

Delivering the chemotherapy drugs directly into the abdominal cavity reduces the risk of damaging vital organs and tissues. When chemotherapy is administered systemically (through an IV), the drugs enter the bloodstream and travel throughout the body, potentially harming healthy vital organs. 

Side Effects of Epithelioid Mesothelioma Chemotherapy 

There are many potential side effects of chemotherapy, varying from manageable to severe. Some of the most common side effects of epithelioma mesothelioma chemotherapy are:

More severe side effects of chemotherapy for epithelioid mesothelioma may be:

Immunotherapy is an emerging treatment option for epithelioid mesothelioma. The goal of this therapy is to boost the immune system’s response to cancer cells and other foreign invaders. 

Immunotherapy drugs attach to cancer cells, which alerts the immune system. Once the immune system recognizes cancer, it can target cells with similar antigens (proteins on cancer cells). At this point, the immunotherapy drugs have successfully increased the immune system’s response to cancer cells. The immune system can now target the remaining cancer cells without harming healthy cells in the body. 

There are a few FDA-approved immunotherapy drugs: Opdivo, Yervoy, and Keytruda. These drugs have been approved specifically for pleural mesothelioma immunotherapy. Specialists support the use of immunotherapy for peritoneal mesothelioma as well, and clinical trials are underway.

The primary immunotherapy drugs for mesothelioma are:

• Imfinzi, brand name for durvalumab
• Keytruda, brand name for pembrolizumab
• Opdivo, brand name for nivolumab
• Yervoy, brand name for ipilimumab

Side Effects of Epithelioid Mesothelioma Immunotherapy 

One of the advantages of immunotherapy is the lack of extreme side effects compared to chemotherapy. However, patients may still experience side effects from epithelioid mesothelioma immunotherapy, including: 

Radiation therapy is a treatment method for epithelioid pleural mesothelioma. It is not often used to treat epithelioid peritoneal mesothelioma due to the vital organs in the abdominal cavity that can be harmed by radiation.

Radiation involves the delivery of high-energy radiation beams to tumors. It is similar to receiving an X-ray and is painless for the patient. Mesothelioma specialists use a linear accelerator to send the beams into the body. It targets and reduces tumor size before or after mesothelioma surgery. Radiation does not kill cancer cells immediately, but it does cause long-term damage to the cells, which can eventually cause the cells to die. 

There are different types of radiation used to treat epithelioid pleural mesothelioma, such as photon radiation (traditional method), intensity-modulated radiation therapy (IMRT), proton radiation and intraoperative radiation therapy (IORT).  

Side Effects of Epithelioid Mesothelioma Radiation 

As previously mentioned, radiation therapy is only used for pleural mesothelioma treatment, which means side effects primarily include damage to lung tissue. Radiation damage to the lungs can lead to scarring, which is a medical condition known as pulmonary fibrosis. 

Other side effects of epithelioid mesothelioma radiation may include:

• Nausea
• Fatigue
• Skin irritation (burning, itchiness, dryness or peeling)
• Coughing
• Shortness of breath 

Multimodal treatment involves multiple methods of treatment. The most common multimodal treatment approaches involve combining surgery, chemotherapy, immunotherapy and radiation. The goal is to attack mesothelioma tumors in various ways, increasing the effectiveness of treatment. 

Applying multiple mesothelioma treatment methods can result in increased survival. In some cases, survival increased by three years, with some patients surviving for more than five years.

Optune Lua (NovoTTG-100F System) was approved by the FDA for the treatment of unresectable pleural mesothelioma, as long as it is paired with chemotherapy. This therapy can be prescribed for patients with epithelioid pleural mesothelioma. Optune Lua is a wearable device that creates tumor treating fields, or electrical fields, to interrupt cancer cell division.

The device must be worn 23 hours a day and produces low-intensity electric fields at a medium frequency to target tumors in the chest cavity. The disruption of cell division can destroy cancer cells, which leads to shrinking tumors and minimizing the spread of mesothelioma. 

Palliative care is a type of treatment aimed at improving the patient’s quality of life. The goal is to minimize symptoms, manage treatment side effects, reduce pain, and provide emotional and spiritual support. Mesothelioma specialists use different methods when providing palliative care, including draining fluid buildup, reducing chest or abdominal pressure and supporting the patient’s and caregiver’s psychosocial needs.

Clinical trials are medical studies performed by clinicians and specialists to test the effects of experimental treatment approaches. Patients can participate in clinical trials and get access to innovative treatments and therapies not yet approved by the FDA. 

When patients are diagnosed with epithelioid mesothelioma, their doctor will usually inform them of potential treatment options, which may include clinical trials. Top cancer centers are typically hubs for hosting clinical trials. Enrolling in a clinical trial can also save the patient and their family money, as the treatment cost is usually covered by a grant or the hospital. Travel costs are also typically covered for patients who do not live near the cancer center.