Clinical characteristics, treatment and survival outcomes in malignant mesothelioma: eighteen years' experience in Turkey

Malignant Pleural Mesothelioma with Bone Marrow Metastases

A 64-year-old man with the bone marrow metastasis due to malignant pleural mesothelioma (MPM) was diagnosed with anemia, leukoerythroblastosis, thrombocytopenia, and lower back pain. A bone marrow biopsy demonstrated infiltrative malignant mesothelioma lesions in the bone marrow. The patient died within 15 days of the detection of the bone marrow involvement. Physicians should consider performing a bone marrow biopsy to diagnose bone marrow metastasis and treat patients with palliative chemotherapy at an earlier phase of the disease. To our knowledge, this is the first report of an MPM patient having bone marrow metastasis with anemia, leukoerythroblastosis, and thrombocytopenia.

Symptom burden in mesothelioma patients admitted to home palliative care

CONTEXT

Mesothelioma is a very aggressive cancer that is brought on by asbestos exposure. Because there is a long latency period between exposure to asbestos and symptoms of disease, most patients with mesothelioma present with advanced disease and survive an average of 8-12 months. Thus, best supportive care should be considered critical to optimally manage these patients.

AIM

The aim of this study was to examine the epidemiological characteristics and symptom burden of mesothelioma patients when admitted to home palliative care.

METHODS

The charts of a consecutive sample of patients admitted to the home palliative care program with a diagnosis of mesothelioma in an endemic industrialized area were reviewed. The estimated survival time was about two months from admission. Epidemiological characteristics were collected. Karnofsky status, characteristics of pain and analgesic treatment at time of admission were recorded. ESAS (Edmonton Symptom Assessment System) and other clinical problems reported in the charts at admission time were also recorded.

RESULTS

Of the 674 charts reviewed, 56 patients (8.3%) had a diagnosis of mesothelioma. About three quarters of those had pain, with 18 and 2 patients with moderate and severe pain, respectively, despite receiving medium to high doses of opioids. The principal pain site was the chest. Pain was significantly associated with opioid consumption (p < .0005) and dyspnea (p = .049). Symptom burden was relevant, with a global ESAS of about 40. Pain, weakness, poor appetite, poor well-being, and dyspnea were the most frequent symptoms with the highest intensity; cough and pleural effusion were more frequently present as clinical problems.

CONCLUSION

This study shows that mesothelioma is a devastating cancer with a relevant symptom burden, and that patients were referred to palliative care late in the course of their disease, suggesting that earlier integration of palliative care should be considered to relieve suffering in all disease stages - not only at the end of life.

Management of malignant pleural mesothelioma: a French multicenter retrospective study (GFPC 0802 study)

BACKGROUND

Malignant pleural mesothelioma (MPM) is a rare disease with poor prognosis in spite of significant improvement in survival, due to new chemotherapy regimens. We describe here patients' profiles and management in daily practice in France.

METHODS

Observational retrospective study. Data were collected from medical files. All patients with histologically proven MPM diagnosed from January 2005 to December 2008 were included in the participating sites.

RESULTS

Four hundred and six patients were included in 37 sites: mean age 68.9 ± 9.8 years, male predominance (sex ratio 3.27), latency of the disease 45.7 years, epithelioïd type 83 %. Diagnosis was made using thoracoscopy in 80.8 % of patients. Radical surgery was performed in 6.2 % of cases. Chemotherapy was administered to 74.6 % of patients. First line regimens consisted mainly of platinum + pemetrexed (91 %) or pemetrexed alone (7 %). Objective response rate was 17.2 % and another 41.6 % of patients experienced disease stabilization. Half of these patients underwent second line chemotherapy (platinium + pemetrexed 31.6 %, pemetrexed alone 24.6 %), resulting in a 6 % response rate. Third-line chemotherapy (56 patients) yielded disease control in 5.4 % of cases.

CONCLUSIONS

The management of MPM in France is usually in accordance with guidelines. Response rates are somewhat lower than those described in clinical trials.

Caring for patients with malignant pleural mesothelioma in Japan: evaluation of a Palliative Care Educational Program

PURPOSE

This study evaluated the effect of an Educational PROGRAM on Palliative Care for MPM for Nurses in Japan.

PROGRAM

The 5-h program consisted of lectures and care planning group work.

MATERIALS AND METHODS

This study used a pretest-posttest design with a single cohort of nurses and included a Difficulties in Palliative Care for Patients with MPM (DPCMPM) Scale with 15 items. The pre- and posttest scores were compared using a t-test.

RESULTS

We included 27 female nurses with a mean of 14.4 years of nursing experience. In 12 of 15 DPCMPM items, the posttest difficulty scores were lower than the pretest scores. Participants highly evaluated the program for validity, clarity, clinical usefulness, and the facilitators. The Palliative Care for MPM Handbook for Nurses was developed as an educational tool for clinical settings.

CONCLUSIONS

The Educational PROGRAM on Palliative Care for MPM for Nurses was effective in reducing nursing difficulties.

Relationship between prognosis and neutrophil: lymphocyte and platelet:lymphocyte ratios in patients with malignant pleural mesotheliomas

BACKGROUND

It has been demonstrated that neutrophil:lymphocyte (NLR) and platelet:lymphocyte (PLR) ratios are associated with prognosis in cancer patients. The aim of this study was to investigate whether pretreatment white blood cell (WBC), neutrophil, lymphocyte, monocyte, platelet, basophil and eosinophil counts, LDH level, NLR and PLR are associated with prognosis in patients with malignant pleural mesothelioma (MPM).

MATERIALS AND METHODS

We retrospectively reviewed files of 50 patients who were managed with a diagnosis of MPM between 2005 and 2010. Demographic and clinical characteristics, treatments, response to treatment and prognostic factors were evaluated, along with relationships between pretreatment blood parameters and prognosis.

RESULTS

Overall, 38 men and 12 women were included to the study. Mean age was 61.5±9.4 years (range: 39-83 years). There was advanced disease in 86% (n=43) and the histological type was epithelial mesothelioma in the majority (82%). Of the cases, 17 (34%) received radiotherapy, while 42 cases underwent first- and second-line chemotherapy, with cisplatin plus pemetrexed as the most commonly used regimen. In the assessment after therapy, it was found that there was complete response in 4 cases (8%), partial response in 10 cases (20%), stable disease in 17 cases (34%) and progression in 19 cases (38%). Median follow-up was 10 months (range: 10 day-30 months). Median overall survival was found to be 20.7 months while median progression-free survival as 10 months. In univariate and multivariate analyses, it was found that factors significantly affecting overall survival included stage (p=0.030), response to treatment (p=0.026) and monocyte count (p=0.004), while factors affecting disease-free survival included NLR (p=0.018), response to treatment (p=0.001), and PLR score (p=0.003).

CONCLUSIONS

Overall and disease-free survival was found to be better in cases with a WBC count<8.000, platelet count<300,000, and low NLR and PLR scores in malignant pleural mesothelioma.

Oral cyclophosphamide and etoposide in treatment of malignant pleural mesothelioma

BACKGROUND

Malignant mesothelioma (MM) is almost always fatal and few treatment options are available. The aim of this study was to evaluate the efficacy of oral cyclophosphamide and etoposide for patients who underwent standard treatment for advanced MM.

MATERIALS AND METHODS

This study included 22 malignant pleural mesothelioma patients who were treated with oral cyclophosphamide and etoposide (EE).

RESULTS

The average follow-up period of the patients was 39.1 months. Under the treatment of oral EE, median progression- free survival was 7.7 months [95%CI HR (4.3-11.1)] and median overall survival was 28.1 months [95%CI HR (5.8-50.3)]. The treatment response rates were as follows: 4 patients (27.3%) had a partial response (PR), 12 (54.5%) had stable disease (SD), and progressive disease (PD) was observed in 6 (35.9%).

CONCLUSIONS

Oral EE can be administered effectively to patients with inoperable malignant mesothelioma who had previously received standard treatments.

Incidental finding of a malignant tumour in an inguinal hernia sac

Metastatic carcinomas in hernial sacs are rare, especially in bilateral femoral hernias. Here we describe a 63-year-old female patient with metastatic carcinoma in bilateral femoral hernias. She was diagnosed incidentally during femoral hernioplasty. A diagnostic laparoscopy revealed metastatic nodules in the abdominal cavity. Subsequently, the patient underwent a laparotomy that did not show any evidence of primary lesions. A chemotherapeutic pump was implanted into the abdominal cavity during surgery for postoperative chemotherapy. The chemotherapy regimen included 5-Fu, hydroxycamptothecin, and pirarubicin, supplemented with high agglomerative staphylococcin. Forty-one months after surgery her disease was stable and no abdominal cavity, pelvis, liver or lung metastases were observed. Therefore, we suggest that abnormal hernial sacs may be the first clue to an underlying cancer, and should be sent for histological examination. Furthermore, if a patient is found to have metastatic abdominal cancer with no evidence of primary lesions, they would probably benefit from postoperative chemotherapy. This can be delivered using a chemotherapeutic pump implanted during surgery.

Polymorphisms in folate pathway and pemetrexed treatment outcome in patients with malignant pleural mesothelioma

INTRODUCTION

A combination of pemetrexed and cisplatin has been shown to improve the outcome in patients with malignant pleural mesothelioma (MPM), however, there is a great heterogeneity in treatment response among patients. The aim of our study was to evaluate the influence of polymorphisms in folate pathway and transporter genes on pemetrexed treatment outcome in Slovenian patients with MPM.

METHODS

MPM patients treated with pemetrexed in the course of a prospective randomized clinical trial were genotyped for nineteen polymorphisms in five genes of folate pathway and six transporter genes. Logistic regression was used to assess the influence of polymorphisms on treatment efficacy and toxicity, while Cox regression was used to determine their influence on progression-free and overall survival.

RESULTS

Patients with at least one polymorphic MTHFD1 rs2236225 allele had a significantly lower response rate (p = 0.005; odds ratio [OR] = 0.12; 95% confidence interval [CI] = 0.03-0.54) and shorter progression-free survival (p = 0.032; hazard ratio [HR] = 3.10; 95% CI = 1.10-8.74) than non-carriers. Polymorphisms in transporter genes did not influence survival; however, several were associated with toxicity. Liver toxicity was significantly lower in carriers of polymorphic ABCC2 rs2273697 (p = 0.028; OR = 0.23; 95% CI = 0.06-0.85), SLCO1B1 rs4149056 (p = 0.028; OR = 0.23; 95% CI = 0.06-0.85) and rs11045879 (p = 0.014; OR = 0.18; 95% CI = 0.05-0.71) alleles compared to non-carriers, as well as in patients with SLCO1B1 GCAC haplotype (p = 0.048; OR = 0.17; 95% CI = 0.03-0.98). Gastrointestinal toxicity was much more common in patients with polymorphic ABCC2 rs717620 allele (p = 0.004; OR = 10.67; 95% CI = 2.15-52.85) and ABCC2 CAG haplotype (p = 0.006; OR = 5.67; 95% CI = 1.64-19.66).

CONCLUSIONS

MTHFD1 polymorphism affected treatment response and survival, while polymorphisms in ABCC2 and SLCO1B1 transporter genes influenced the risk for toxicity. These polymorphisms could serve as potential markers of pemetrexed treatment outcome in patients with MPM.