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What is Malignant Mesothelioma?
Cancer begins when normal cells change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body).
Mesothelioma is a rare cancer that begins in the lining of the internal organs of the body. Approximately three-fourths of mesotheliomas begin in the lining surrounding the lungs, called pleural mesothelioma. While pleural mesothelioma does begin in the chest cavity, it does not start in the lungs, and it is often incorrectly grouped with lung cancer. Mesothelioma that begins in the tissue surrounding the abdominal area, called peritoneal mesothelioma, accounts for about 10% to 20% of mesotheliomas. The rarest type of mesothelioma begins in the lining around a man's testicles, called the tunica vaginalis.
There are three main types of mesothelioma:
Epithelioid type. The epithelioid type accounts for about 70% of people diagnosed with mesothelioma. This type of mesothelioma may grow slower and is more likely to respond to treatment.
Sarcomatoid type. The sarcomatoid type accounts for 7% to 20% of people diagnosed with mesothelioma and has a worse prognosis. It generally does not respond well to chemotherapy.
Mixed, or biphasic, type. The mixed type accounts for 10% to 20% of people diagnosed with mesothelioma and contains both epithelioid and sarcomatoid types. This type of mesothelioma has an intermediate prognosis.
Symptoms and Signs
People with mesothelioma may experience the following symptoms or signs. Sometimes, people with mesothelioma do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. Often, symptoms of mesothelioma may not appear until years or even decades after asbestos exposure. If you are concerned about a symptom or sign on this list, please talk to your doctor.
If mesothelioma is in the chest area, called pleural mesothelioma, the symptoms may include:
a) Shortness of breath, caused by thickening of the lining around the lung limiting the ability of the lungs to expand
b) Build-up of fluid in the chest, called a pleural effusion
c) Pain in the chest
If mesothelioma is in the abdominal area, called peritoneal mesothelioma, the symptoms may include:
a) Abdominal pain
b) Abdominal swelling from a buildup of fluid, called ascites
c) Bowel obstruction
General symptoms of mesothelioma may include:
a) Weight loss
c) Problems with blood clotting
d) Anemia (low level of red blood cells)
f) Night sweats
Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you've been experiencing the symptom(s) and how often.
If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.
A risk factor is anything that increases a person's chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.
The following factors can raise a person's risk of developing mesothelioma:
Asbestos exposure. Between 70% to 80% of people diagnosed with mesothelioma have a history of asbestos exposure. Asbestos is a group of natural minerals found in the earth. Because of its strong, flexible fibers, asbestos was once commonly added to cement, insulation, roof shingles, and other products. People involved in the manufacturing of products containing asbestos or their installation and maintenance can breathe in or swallow the asbestos fibers. These fibers can also be carried in asbestos dust on clothing or personal items, exposing family members of the workers to potentially high levels of the minerals. Current safety regulations require people who work with asbestos to wear protective equipment and to shower and change clothes before leaving the workplace.
Smoking. By itself, smoking does not increase the risk of mesothelioma, but the combination of smoking and asbestos exposure greatly increases the risk of certain types of cancer in the lung.
Radiation exposure. Radiation exposure may cause mesothelioma.
Zeolite exposure. Exposure to a type of mineral called zeolite may cause mesothelioma.
Infection. Infection with certain viruses, such as the simian virus 40 (SV40), may be associated with mesothelioma, although this link has not been proven.
Even though some people with mesothelioma have no known risk factors, many people who develop mesothelioma have been exposed to asbestos. Therefore, it is important to always wear protective gear and follow safety precautions when working with asbestos.
Doctors use many tests to diagnose cancer and find out if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:
Age and medical condition
Type of cancer suspected
Severity of symptoms
Previous test results
The diagnosis of mesothelioma is challenging, and it can be confused with other diseases, such as lung cancer.
Many people first notice symptoms of mesothelioma when they develop fluid in the space around the lungs (called pleural effusion) or in the abdomen (called ascites). When this fluid is removed, it can be analyzed to see if there are cancer cells in it. However, testing this fluid is usually not the only test needed to diagnose the disease; a biopsy is usually required to diagnose mesothelioma.
Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed during the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). A biopsy is usually needed to confirm a diagnosis of mesothelioma. Sometimes, a needle can be used to get a sample of the lining. More often the doctor removes a tissue sample by using a thin, lighted tube inserted through a small incision in the body. This is called a video thoracoscopy when used to get samples from inside the chest or a laparoscopy when used to get tissue samples from inside the abdomen.
The following procedures may be used to help develop a treatment plan:
Physical examination. A physical examination may include a medical history of the person and his or her family's past illnesses, a list of their risk factors (including asbestos exposure), and an examination for other signs of cancer.
Lung function tests. Also called pulmonary function tests or PFTs, lung function tests evaluate how much air the lungs can hold, how quickly air can move in and out of the lungs, and how well the lungs add oxygen and remove carbon dioxide from the blood.
X-ray. An x-ray is a way to create a picture of the structures inside of the body using a small amount of radiation. An x-ray of the chest can sometimes help doctors determine whether a person has mesothelioma and where it is located, but it is not the main way to diagnose mesothelioma.
Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then puts these images into a detailed, cross-sectional view that shows abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient's vein to provide better detail.
Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient's vein to create a clearer picture.
Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient's body. This substance is absorbed mainly by organs and tissues that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.
Staging is a way of describing where the cancer is located, if or where it has spread, and whether 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 prognosis (chance of recovery). There are different stage descriptions for different types of cancers.
This section describes the staging system for pleural mesothelioma. Currently, there is no standard staging system for peritoneal mesothelioma.
One tool that doctors use to describe the stage is the TNM system. This system judges three factors: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to the rest of the body. The results are combined to determine the stage of cancer for each person. There are four stages for pleural mesothelioma: stages I through IV (one through four). The stage provides a common way of describing the cancer so doctors can work together to plan the best treatments.
TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:
How extensive is the primary tumor and where is it located? (Tumor, T)
Has the tumor spread to the lymph nodes? (Node, N)
Has the cancer metastasized to other parts of the body? (Metastasis, M)
Tumor. Using the TNM system, the "T" plus a letter and/or number (0 to 4) is used to describe the stage of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. This helps the doctor develop the best treatment plan for each patient. Specific tumor stage information is listed below:
T1: The tumor has invaded the thin membrane that lines the lung and inner chest walls on one side of the body, called the ipsilateral pleura.
T1a: The tumor involves the ipsilateral parietal pleura (the thin lining around the chest wall), with no involvement of the visceral pleura (the thin lining around the lung).
T1b: The tumor has invaded the ipsilateral parietal pleura and the visceral pleura.
T2: The tumor involves any of the ipsilateral pleural surfaces and invades either the diaphragm (the muscle that separates the chest cavity from the abdomen) or the lung.
T3: The tumor involves any of the ipsilateral pleural surfaces, with at least one of the following: invasion of the membrane that surrounds the thorax, called the endothoracic fascia; invasion into the mediastinum (the area of the chest between the lungs); a single area of invasion into the muscles of the chest wall; or minimal invasion into the lining around the heart, called the pericardium.
T4: The tumor involves any of the ipsilateral pleural surfaces, with at least one of the following:
Invasion in several areas of the chest wall with or without involvement of rib
Invasion through the diaphragm to the abdominal cavity
Invasion of any mediastinal organ(s), such as large blood vessels
Extension to the pleura on the opposite side of the body
Invasion into the spine
Extension though the pericardium which may cause fluid buildup, or invasion of the heart.
Node. The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the chest are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.
NX: The regional lymph nodes cannot be evaluated.
N0 (N plus zero): Cancer has not spread to the regional lymph nodes.
N1: Cancer has spread to the bronchopulmonary lymph nodes (located within the lungs) on one side of the body and/or hilar lymph node(s) (near the larger airways of the lungs).
N2: Cancer has spread to the subcarinal lymph node(s) (surrounding the windpipe) and/or the mediastinal lymph node(s) (located in the center of the chest between the lobes of the lungs) on one side of the body, including the internal mammary lymph nodes (near the breast bone) on one side of the body and the peridiaphragmatic lymph nodes (surrounding the diaphragm).
N3: Cancer has spread to the mediastinal lymph nodes on both sides of the body, the internal mammary lymph nodes and/or supraclavicular lymph node(s) (above the collar bone) on one or both sides of the body.
Distant metastasis. The “M” in the TNM system indicates whether the cancer has spread to other parts of the body.
M0 (M plus zero): Cancer has not spread to other parts of the body.
M1: Cancer has spread to other parts of the body.
Cancer stage grouping
Doctors assign the stage of the cancer by combining the T, N, and M classifications.
Stage I: The tumor has invaded the ipsilateral parietal pleura, with or without involvement of the visceral pleura, but has not spread to the lymph nodes or other parts of the body (T1, N0, M0).
Stage IA: The tumor has invaded the ipsilateral parietal pleura, without involvement of the visceral pleura, but has not spread to the lymph nodes or other parts of the body (T1a, N0, M0).
Stage IB: The tumor has invaded the ipsilateral parietal pleura, with involvement of the visceral pleura, but has not spread to the lymph nodes or other parts of the body (T1b, N0, M0).
Stage II: The tumor is defined as T2 (see above), and cancer has not spread to the lymph nodes or throughout the body (T2, N0, M0).
Stage III: Any of the following conditions:
The tumor is defined as T1 or T2 (see above). Cancer has spread to the lymph nodes described above as N1 or N2 but not to other parts of the body (T1 or T2, N1 or N2, M0).
The tumor is defined as T3 (see above), and cancer may or may not have spread to lymph nodes and has not spread to other parts of the body (T3, N0-2, M0).
Stage IV: Any of the following conditions:
The tumor is defined as T4 (see above). Cancer may or may not have spread to the lymph nodes and has not spread to other parts of the body (T4, any N, M0).
Cancer has spread to lymph nodes described above as N3 but not to other parts of the body (any T, N3, M0).
Cancer may or may not have spread to the lymph nodes and has spread to other parts of the body (any T, any N, M1).
Recurrent: Recurrent cancer is cancer that comes back after treatment. It may return in the chest or in another part of the body. If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above.
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