Pleura

1. Weight Loss 2. Chest Pain 3. Dyspnea 4. Cough 5. Hemoptysis 6. Chest Wall Pain 7. Pleural effusion, or fluid surrounding the lung 8. Shortness of Breath 9. Fatigue or Anemia 10. Wheezing 11. Hoarseness of voice 12. Blood in the sputum (fluid) coughed up (hemoptysis) 11  The more common symptoms of mesothelioma are shortness of breath, chest and/or abdomen pain, and fatigue. The less common symptoms are a persistent cough, significant weight loss, hemoptysis, dysphagia, hoarseness, nausea, and low oxygen levels. In patients that have mesothelioma, fluid builds up in the space between the two membranes which puts pressure on the lung and can cause the lung to collapse. 8 || A physical exam can provide information about possible signs of mesothelioma and other health problems. Patients with pleural mesotheliomas often have fluid in their chest cavity (pleural effusion) caused by the cancer. Fluid can build up in the abdominal cavity (ascites) in cases of peritoneal mesothelioma, or in the pericardium (pericardial effusion) in cases of pericardial mesothelioma. Rarely, mesothelioma can develop in the groin and look like a hernia. All of these might be found during a physical exam. If symptoms and/or the results of the physical exam suggest a mesothelioma might be present, more involved tests will likely be done. These might include imaging tests, blood tests, and other procedures. Imaging tests use x-rays, radioactive particles, or magnetic fields to create pictures of the inside of your body. Imaging tests may be done for a number of reasons, including to help find a suspicious area that might be cancerous, to learn how far cancer may have spread, and to help determine if treatment has been effective." 12  || 1. Sarcomatous 2. Epithelial 3. Mixed 13 || -“Extrathoracic lymph node metastasis is a very rare occurance in diffuse malignant mesothelioma.” 4  -“The lymphatic vessels of the parietal pleural drain anteriorly to the parasternal lymph nodes, and centrally to the hilar nodes. The lymphatic drainage of the chest walls is to the axillary lymph nodes; anterior and lateral thoracic wall lymphatics posterior thoracic wall lymphatics to the other axillary nodes.”  4 || //Stage I:// Resectable mesothelioma and no lymph node involvement //Stage II:// Resectable mesothelioma but with lymph node involvement //Stage III:// Unresectable mesothelioma with reach to chest wall, heart, or through diaphragm, peritoneum; with or without extra-thoracic lymph node involvement //Stage IV:// Distant metastatic disease. 5 || Once the T, N, and M categories have been assigned, this information is combined in a process called stage grouping to assign an overall stage of I, II, III, or IV. The stages identify tumors that have a similar prognosis and thus are treated in a similar way. Patients with lower stage numbers tend to have a better prognosis. Stage I Stage II Stage III There are 2 combinations of categories that make up this stage. Stage IV There are 3 combinations of categories that make up this stage.
 * Epidemiology: || The membrane that surrounds the lungs and lines the wall of the chest cavity is called the pleura. Mesothelioma is a rare cancer that can be found in the pleura. Although this cancer has been on the rise over the last 20 years, it is considered rare. 2,000 new cases are reported each year in the United States. 2  The incidence of mesothelioma is more common in men than women. Increased age is also a risk factor, but this disease can occur in either sex at any age. ||
 * Etiology: || The #1 risk factor for mesothelioma is working with asbestos. 70-80% of all patients have a history of asbestos exposure. Smoking does not appear to be a risk factor, but the combination of asbestos exposuer and smoking has proven to increase chances of developing this cancer. 2 ||
 * Signs & Symptoms: || Signs and Symptoms of Pleural Cancer:
 * Diagnostic Procedures: || <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">"If you have any signs or symptoms that suggest you might have mesothelioma, your doctor will want to take a complete medical history to check for symptoms and possible risk factors, especially asbestos exposure. You will also be asked about your general health.
 * Histology: || <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">3 histological types:
 * Lymph Node Drainage: || <span style="color: #ff00ff; font-family: 'Arial','sans-serif'; font-size: 10pt;">-"It spreads to the lower paraesophageal modes, pulmonary ligament nodes, and diaphragmatic nodes." <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 9pt; vertical-align: super;">1 <span style="color: #ff00ff; font-family: 'Arial','sans-serif'; font-size: 10pt;">
 * Metastatic Spread: || Mesothelioma spreads by direct extension, seeding throughout the pleural space ( fissures, diaphragmatic and pericardial), through the chest wall, and into the mediastinum, peritoneum and lymph nodes. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 90%; vertical-align: super;">1 ||
 * Grading: || The grading system (Brigham System) is as follows:
 * Staging: || TNM Stage grouping for pleural mesothelioma
 * T1, N0, M0:** Mesothelioma involves either the right or left pleura lining the chest wall or diaphragm. It may or may not have spread to small spots on the pleura covering the lung as well. It has not spread to the lymph nodes or to distant sites.
 * T2, N0, M0:** Mesothelioma involves either the right or left pleura lining the chest wall or diaphragm and has grown into a large area of the pleura lining the lung, the diaphragm, or the lung itself. It has not spread to the lymph nodes or to distant sites.
 * T1 or T2, N1 or N2, M0:** Mesothelioma involves either the right or left pleura lining the chest and may or may not have grown into the pleura lining the lung, the diaphragm, or into the lung itself. It has spread to lymph nodes in the chest on the same side as the tumor. It has not spread to distant sites.
 * T3, N0-2, M0:** Mesothelioma involves either the right or left pleura lining the chest and has grown into the first layer of the chest wall, the fatty part of the mediastinum, a single place in the deeper layers of the chest wall, or the outer covering layer of the heart. It may or may not have spread to lymph nodes in the chest on the same side as the tumor but has not spread to lymph nodes near the collarbone or on the opposite side of the chest. It has not spread to distant sites.
 * T4, any N, M0:** Mesothelioma involves either the right or left pleura lining the chest and has spread into the deeper layers of the chest wall (including the muscle or ribs), through the diaphragm and into the peritoneum, into any organ in the mediastinum, into the spine, across to the pleura on the other side of the chest, through the heart lining or into the heart itself, or into the brachial plexus. It may or may not have spread to lymph nodes. It has not spread to distant sites
 * Any T, N3, M0:** The tumor is of any size. It has spread to lymph nodes near the collarbone on either side and/or to hilar or mediastinal lymph nodes on the side opposite the primary tumor. It has not spread to distant sites
 * Any T, any N, M1:** The mesothelioma is of any size and may or may not have spread to the lymph nodes. It has spread to distant sites 6  ||
 * Radiation Side Effects: || <span style="color: #ff0000; font-family: 'Times New Roman',Times,serif; font-size: 12pt;">“One of the problems with radiation therapy for malignant pleural mesothelioma is that the cancer is usually widespread, requiring a large area to be irradiated. The high doses of radiation necessary for eradication of disease may cause sunburn like changes to the skin, fatigue, and damage to normal structures in the chest. Complications of radiation therapy for malignant pleural mesothelioma include inflammation of the lungs (pneumonitis), inflammation of the sack around the heart (pericarditis), and compression of the heart (cardiac tamponade).” <span style="color: #ff0000; font-family: 'Times New Roman',Times,serif; font-size: 10.8pt; vertical-align: super;">9 ||
 * Prognosis: || <span style="color: #0000ff; font-family: Georgia,serif;">The median survival for malignat mesothelioma patients is one year from diagnosis. Male patients and those with elevated white-cell counts, thrombocytosis, or anemia have a worse prognosis. The histology, stage and extent of cancer are important prognostic factors. The patients age and response to treatment also affects prognosis. In general, younger patients that report no weight loss at diagnosis do better. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 90%; vertical-align: super;">3 ||
 * Treatments: || <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">The treatment for mesotheilioma can require surgery, chemo, and radiation. The type of treatment one receives depends on the stage of the diesease, where the cancer is located, as wells as the age and overall health of the patient. Although this is a very resistant<span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;"> disease, aggressive therapy may result in long-term survival and possibly cure. Most mesotheilioma patients who have been cancer-free for a long time after treatment, had surgery as a part of their treatment regimen. For patients who cannot have surgery, new agents "that target crucial pathways that regulate MPM cells have offered new hope for improving outcomes."

__**Surgery**__

There are two main goals of MPM. These are to: <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">There are two types of surgery available: <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;"> <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;"> In patients who have surgery, M.D. Anderson recommends giving chemo as part of a multi-modality treatment. They recommend that patient consider enrolling in a clinical trial which provides surgery, radiation, chemo, and a biologic target agent. In patients that are unable to have surgery, treating with chemo is an option as well as a clinical study with the new targeted agents being used. Chemo does not cure mesothelioma so M.D. Anderson recommends the clinical trials where chemo is used in combination with biologic therapy or where the biologic agent is used by itself. "The current standard practice in the United States (when not on a clinical trial) is to receive treatment with chemotherapy agents cisplatin or carboplatin and pemetrexed (Alimta). Other chemotherapy drugs that are commonly used include gemcitabine and vinorelbine. However, the future of systemic therapy for mesothelioma will be focused on targeted agents and personalized medicine. Personalized medicine means that the choice of treatment will be based on the individual cancer's specific genetic/molecular profile."
 * <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">"Reduce the overall volume of disease to increase the likelihood of cure with additional therapy such as radiation and chemotherapy and targeted/biologic agents."
 * <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Help with symptoms such as pain and shortness of breath.
 * <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Pleurectomy of Pleurectomy/Decortication (P/D)--This is where the tumor is peeled away from the lung, diaphragm and chest wall while leaving the structures intact. When this is done, one can't receive high doses of radiation because the lung and diaphragm remain intact. Local recurrences are more common with this type of surgery than they are with the next type. This type of surgery is performed when the patient cannot tolerate extrapleural pneumonectomy because of having poor heart or lung function.
 * <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Extrapleural pneumonectomy(EPP)--At M.D. Anderson, EPP is thought to be the best chance of complete tumor removal. In addition, it allows other therapies to be given with less risk to the vital organs that remain. The surgery itself is an indepth surgery that includes removing all of the organs involved (lung, lymph glands, and parts of the diaphragm and pericardium. Next, the diaphragm and pericardium are reconstructed with an artificial material. In order to withstand this surgery, the patient must be in good physical shape.
 * __Chemotherapy__**

__**Radiation**__ Radiation by itself isn't a successful curative treatment for mesothelioma. When administered with surgery, it can help to reduce the chances of recurrence. Other instances in which it is used is when it is given as prophylaxis to an incision site in order to prevent recurrence or when it is given for palliation. The most common reason for radiation with mesothelioma is to prevent recurrence after surgery. A newer type of radiation treatment for mesothelioma is using IMRT. This type of treatment is given after the patient has an EPP. This technology is hoped to lead to improving outcomes and reducing toxicity to the patients vs hemi-thoracic external beam radiation. <span style="color: #298000; font-family: 'Times New Roman',Times,serif; font-size: 99%; vertical-align: super;">8 <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;"> Common doses delivered with IMRT post-surgery are 54Gy to the CTV in 30 fractions at 180cGy/day. Then there is a boost region that goes to 60 Gy in 30 fractions at 200cGy/day. <span style="color: #298000; font-family: 'Comic Sans MS',cursive; font-size: 89%; vertical-align: super;">10

<span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Figure 1. CTV used for IMRT mesothelioma treatment planning. <span style="color: #298000; font-family: 'Comic Sans MS',cursive; font-size: 99%; vertical-align: super;">10 <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Figure 2. Axial view of CTV mesothelioma for IMRT planning. <span style="color: #298000; font-family: 'Comic Sans MS',cursive; font-size: 79%; vertical-align: super;">10 <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Figure 3. Axial view of CTV mesothelioma for IMRT planning. <span style="color: #298000; font-family: 'Comic Sans MS',cursive; font-size: 88%; vertical-align: super;">10 <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Figure 4. Beam arrangement used for IMRT--Has 160 degrees free from entrance beams. <span style="color: #298000; font-family: 'Comic Sans MS',cursive; font-size: 88%; vertical-align: super;">10 || <span style="color: #298000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Figure 5. TD5/5 for organs near the treatment site. <span style="color: #298000; font-family: 'Times New Roman',Times,serif; font-size: 90%; vertical-align: super;">7 || Kim is the <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 121%;"> teal green <span style="font-family: 'Times New Roman',Times,serif; font-size: 131.76%;">. <span style="font-family: 'Times New Roman',Times,serif; font-size: 119.79%;">Kristy is the <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 119.79%;">fushia/bright purple <span style="font-family: 'Times New Roman',Times,serif; font-size: 119.79%;">. <span style="font-family: 'Times New Roman',Times,serif; font-size: 121%;">Stacy is the <span style="color: #298000; font-family: 'Comic Sans MS',cursive; font-size: 120%;">darker green <span style="font-family: 'Times New Roman',Times,serif; font-size: 121%;">. Shae is the <span style="color: #ff0000; font-family: 'Times New Roman',Times,serif; font-size: 121%;"> red <span style="font-family: 'Times New Roman',Times,serif; font-size: 121%;">. <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;"> || References: 1. Gunderson, LL & Tepper, JE. (Eds.) //<span style="font-family: 'Calibri','sans-serif';">Clinical Radiation Oncology //. 2nd edition. Philadelphia, PA: Elsevier, Churchill & Livingstone. 2007: 987-996. <span style="color: #0000ff; font-family: Georgia,serif;">2. National Cancer Institute.Available at []. Accessed on Jan. 20, 2010. 3. []. Accessed on Jan. 23, 2010. 4. <span style="color: #ff00ff; font-family: 'Arial','sans-serif';">Kim, SB., Varkey, B. & Choi, H. (1987) //Diagnosis of malignant pleura mesothelioma by axillary lymph node biopsy. The American College of Chest Physicians Journal, 91,279-279.// Retrieved from []. 5. Mesoblog.org. (2009). //Survival Rates of Mesothelioma Cancer at its Last Stages//. Retrieved on January 22, 2010, from Mesoblog Website at []. 6. American Cancer Society. Detailed Guide:Malignant Mesothelioma. Available at: []. Accessed on January 24, 2010. <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">7. Washington CM, Leaver D. //Principles and Practice of Radiation Therapy.// 2nd edition. St. Louis, MO: Mosby, Inc. 2004: 671. 8. The University of Texas MD Anderson Cancer Center. //Mesothelioma.// Available at: [] Accessed January 24, 2010. 9. University of Flordia Shands Cancer Center. Radiation Therapy for Malignant Pleural Mesothelioma. Available at: [] Accessed: January 24, 2010. <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">10. Schofield D, Court L, Allen A, Hacker F, Czerminska M. //<span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Calculation of Contra Contra-lateral Lung Doses in Thoracic IMRT: AnmExperimental Evaluation. //<span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Available at: [] Accessed: January 24, 2010. <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 121%;">11. Symptoms of Pleural Cancer. Wrong Diagnosis.com. Available at: <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;"> []. <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Accessed on: January 22, 2010. 12. How Is Malignant Mesothelioma Diagnosed? American Cancer Society. Available at: <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;"> []. <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Accessed on: January 23, 2010. 13. Mesothelioma. eMedicine. Available at: []. <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Accessed on: January 23, 2010.
 * 10TD5/5: || [[image:pleura_td55new.JPG width="260" height="171"]]<span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">
 * || <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;"><span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Holly is the<span style="color: #0000ff; font-family: 'Times New Roman',Times,serif;"> royal blue.