What is angiogensis and what benefit does Squalamax� provide?
Figure 1: Angiogenesis
Angiogenesis is a function in the body where unhealthy cells develop their own blood vessel structure in order to nourish and support themselves (See Figure 1.). The immune system in response uses certain compounds in the body to naturally counter angiogenesis. This normal body function is called anti-angiogenesis. If the immune system is successful in carrying out this designed function of nature, unhealthy cells can not survive. However, if the body is deficient in these vital compounds, anti-angiogenesis can not occur. Therefore, it is important to supplement the body with natural anti-angiogenesis factors such as squalamine which is abundant in the Squalamax� product.
How much Squalamax� should I take daily?
We suggest you take 2 capsules daily (one capsule twice daily on an empty stomach), unless your health challenge is more serious.
NOTE: Preferably take with Ultramarine Shark Liver Oil Gelcaps for optimum benefits.
In which types of cancer tumors does angiogenesis (i.e. growth of new blood vessels needed to support the growth of tumors) occur?
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What is angiogensis and what benefit does Squalamax� provide?
Anal Pain
Anal Pain
Piles / Hemorrhoid
A 39 year old Caucasian with serious bleeding from external piles was seen by a general surgeon who operated on him in February 2005. Following surgery, he continued to have severe pain two months after surgery.
He was seen and re-operated by the same surgeon for piles but continued to have severe pain even on sitting three months after surgery and was referred to see me. Clinical examination showed that he had a previously unrecognized chronic anal fissure with large external skin tags.
He underwent an excision of the skin tags and a simple procedure called a lateral sphincterotomy to cure the chronic fissure and was totally well the following day. Expert examination and accurate diagnosis and surgery will ensure prompt healing and minimal complications in all cases undergoing surgery.
Difficult Rectal Cancer
Rectal Cancer
A 50 year old Caucasian man first complained of anal symptoms including bleeding and anal pain in May 2005. He was seen in Russia initially and was diagnosed to have a very low rectal cancer about 2 cm from the anal verge. Complete removal including removal of the anus was advised in Russia. The patient was adamant against this and sought treatment with me. Clinical examination showed a very muscular and large man who was otherwise very fit for his age.
As the cancer was indeed 2 cm from the outside skin edge an abdominal-perineal excision or removal of the rectum and anus was discussed with him. He was firmly fixed against the idea that he will have a permanent colostomy bag on his abdomen. As all scanning showed that the tumour was localized without spread to other parts of his body, it was felt that it might be possible to attempt an inter-sphincteric dissection of his anus and remove the cancer totally by this method and allow him to preserve anal function.
This operation was performed successfully on the 3rd August. The cancer was removed with a good margin and no chemotherapy or radiotherapy was needed. He remains very well with good ability to control his anus on follow up.
Advanced Rectal Cancer
Cancerous Polyp Cancerous Polyp
A 39 year Chinese man with locally advanced rectal cancer. Mr Chia first presented with difficulty in motion in Jan 2005. He was then in severe pain and had bleeding whenever he went to the toilet. He also passed motion with difficulty and pain. Clinical examination showed a huge rectal mass fixed to the pelvis and protruding into the anal canal. The lower end of the cancer was only 2 cm from the bottom of the anus. He saw a surgeon elsewhere and he was advised that no treatment was possible and that he should go home and await the end.
Mr Chia became desperate until a friend recommended him to see me at Mt Elizabeth Hospital. Clinical examination showed Mr Chia to be a well built man in his late 30’s. He was fit and physical examination showed no abnormality except for the huge fixed cancer in the pelvis and rectum. CT films showed gross infiltration outside the rectum and a huge mass was immediately clearly seen. The cancer was clearly not completely respectable at this stage. He was advised to undergo chemotherapy and radiotherapy in an effort to shrink the cancer. This strategy worked well.
Six weeks of chemo and radiotherapy shrunk the mass completely. After 6 weeks, no residual cancer was felt on rectal examination. Further X rays showed spread elsewhere and Mr Chia was advised for rectal surgery. An ultra-low anterior resection was done on Oct 2006. Histological examination of the resected specimen showed complete clearance of cancer. Mr Chia is expected to have a good prognosis.
Redo of Blotched Up Surgery
Cancerous Polyp
A 63 year old man in another country had a colonoscopy and removal of a colonic polyp on the 10th Jan 2003. The following day, he complained of severe abdominal pain and was hospitalized and underwent emergency surgery on the 13th January 2003. Surgery was performed during which the perforated removal of polyp site was sutured closed and a tube inserted into his caecum.
Unfortunately this too perforated and a second operation was performed on the 19th Jan 2005. However, this was not done in proper fashion and again, an emergency surgery had to be done. The patient became frightened of surgery in his own country and flew to see me on the 11 Jan 2005. Examination showed that he had two stomas(intestinal openings) on his abdomen, one on the right and one on the left. There was also a very large anterior hernia. A complete repair and restoration of all his stomas was suggested by me.
The patient was anxious about more surgery but after consideration, underwent surgery by me on the 15 July 2005. This difficult surgery was successful as the two stomas were restored back to the abdomen and the hernia repaired. The patient made a good recovering and flew home.
Intra-Abdominal Cancer Up Surgery
Cancerous Polyp Cancerous Polyp
Cancerous Polyp Cancerous Polyp
A 28 year old man with huge intra-abdominal cancer. Mr TF first presented in April 2005 in his own country with a problem of a large intra-abdominal swelling. X rays revealed a very large intra-abdominal tumour and he was operated upon. Although 2.5 kg of tumour was removed, the surgery was evidently incomplete. Histological examination showed this to be a desmoplastic small cell tumour. The patient was given a combination of adriamycin, ifosfamide, vincristine, dacarbazine and mesna. However, after 5 cycles, residual mesenteric thickening was still evident. The patient relapsed in Feb 2006. CT scan then showed large soft tissue mass in the pelvis invading the rectum, sigmoid colon, prostate, seminal vesicles and numerous intra-abdominal nodules with a larger mass in the upper abdomen.
He received further chemotherapy but the masses increased in size. In July 2006 he developed severe pain in the buttocks and constipation and examination showed a very large abdominal mass arising from the pelvis. Palliative radiotherapy was given in an attempt to shrink the tumour and he received a total of 4500 cgy in 25 fractions. However repeat CT scans on 17 August 2006 showed further increase in the size of the masses. He was told to go elsewhere for treatment and was finally referred to see me at Mt Elizabeth Hospital.
I first saw Mr TF on the 12 Oct 2006. Physical examination showed a very large abdominal mass up to the level of the umbilicus. Rectal examination showed a hard fixed pelvic mass. CT scans showed a 20 cm large pelvic tumour, a 13 cm abdominal tumour, a 5 cm splenic hilar mass and multiple smaller abdominal masses. He was initially tried on further chemotherapy but no response was noted.
Finally as the pain and constipation became progressively worse, surgery was performed on the 15 Feb 2007. During surgery, despite the hugeness of the mass, expert dissection and manipulation enabled all the masses to be totally removed. Mr TF now has a very good chance of complete cure.
Multimodal treatment of mesothelioma
Doctors specializing in mesothelioma treatment frequently adopt a multimodal approach: they treat a patient with a combination of therapies. Due to the relative lack of effectiveness of single-modality treatment in affecting patient survival, the multimodal combination of treatments holds more promise for survival of malignant mesothelioma patients. For an over view of single-mode and multimodal treatment regimens, see the abstract of "Treatment of Malignant Mesothelioma" by M.T. Jaklitsch, S.C. Grondin, and D.J. Sugarbaker and published in the World Journal of Surgery in 2001.
The December 1999 issue of the medical journal, Chest, published a clinical case presentation that illustrates a fairly typical multimodal treatment. The patient was a 52-year-old man with an early diagnosis of Stage I pleural mesothelioma. Doctors performed a pleurectomy (i.e. surgery) and then delivered intrapleural doses of chemotherapy drugs. Then he received additional localized radiation and chemotherapy. Two years after the surgery he did not show evidence of the tumor.
The author concluded that "Aggressive trimodality therapy for mesothelioma is presented as a successful treatment option." (R. Buono - "Mesothelioma Clinical Presentation", Chest 1999; 116:444S-445S)
In recent years, there has been some progress made in the management of malignant mesothelioma, particularly in the area of combination of agents and treatment methods used. More details can be found in this interview with mesothelioma medical expert, Dr. Nicholas Vogelzang: "New Directions for the Treatment of Mesothelioma: An Expert Interview" (Oncology 6(1), 2003).
The following discussion of mesothelioma treatments is organized into separate sections (surgery, photodynamic therapy, radiation, etc.) so that each component of a combination of treatments (multimodality therapy) can be better understood.
"Multimodality Treatments for Mesothelioma?" by W. Eberhardt, (27th Annual congress of the European Society for Medical Oncology).
Two presentations evaluating multimodal treatment of mesothelioma were part of the program of the 37th Annual Meeting of the American Society of Clinical Oncology, May 12-15, 2001 (San Francisco). The first study, by M. Keohan, et al., used an agressive regimen for their phase II study of trimodal therapy for peritoneal mesothelioma. The second study, by J.V. Juturi, et al., investigated intracavitary paclitaxel in a multimodality management of malignant pleural mesothelioma; two earlier cooperative group studies using this treatment method yielded response rates of 0% and 9%, respectively, in patients with mesothelioma. For information about obtaining ASCO asbstracts, check their webpage.
A.M. Boylan - "Mesothelioma: new concepts in diagnosis and management" in Current Opinion in Pulmonary Medicine, March 2000; 6(2):157-163. An interesting discussion about the difficulties of diagnosing mesothelioma; the controversies about staging mesothelioma; and whether the improved survival rates of some new treatments indicate that these treatments are more effective or are explained by patient selection.
D. H. Sterman, MD, et. al. - "Advances in the Treatment of Malignant Pleural Mesothelioma" in Chest 1999; 116:504-520; (see abstract) This article discusses the roles of chemotherapy, radiotherapy, surgery and combined modality approaches in the treatment of pleural mesotheliomas. Promising new avenues may modify the therapeutic nihilism that is rampant among clinicians dealing with mesothelioma.
Types of Mesothelioma Treatment:
Other Mesotheliomas
While the great majority of mesotheliomas are in either the pleura or the peritoneum, malignant mesotheliomas sometimes occur in other parts of the body, including the testicles (a variety of peritoneal mesothelioma) and the heart (a variety of pleural mesothelioma.) These are also caused by exposure to asbestos fibers.
Benign mesotheliomas occur less frequently than malignant mesotheliomas. They are generally thought to be unrelated to asbestos exposure. Two thirds of benign mesotheliomas occur in females. (Kittle: Mesothelioma Diagnosis and Management, Year Book Medical Publishers, 1987)
Unfortunately, cystic benign mesotheliomas have a high incidence of local recurrence. (Katsube: Cystic Mesothelioma of the Peritoneum; Cancer 1982, 50:1615; Moore: Benign Cystic Mesothelioma; Cancer 1980, 45:2395) A July 1998 article by G.S. Letterie in the journal "Gynecology and Obstetrics" describes therapy with anti-estrogen tamoxifen as a non-surgical option for cases of symptomatic recurrent cystic mesotheliomas.
other Types of cancer:
Peritoneal mesothelioma
Many of the organs in the abdomen are enveloped by a thin membrane of mesothelial cells, known as the peritoneum.
Peritoneal mesothelioma is a tumor of this membrane. Its only known cause in the U.S. is previous exposure to asbestos, but it can be many years after exposure before the disease appears. Peritoneal mesotheliomas account for about one-fifth of all mesotheliomas.
Like pleural mesothelioma, peritoneal mesothelioma can be either benign or malignant. This discussion is only about malignant peritoneal mesothelioma.
Mesothelioma is sometimes diagnosed by coincidence, before any symptoms have appeared. For example, the tumor is sometimes seen on a routine abdominal x-ray for a check-up or before surgery.
When the symptoms of peritoneal mesothelioma appear, they typically include abdominal pains, weakness, weight loss, loss of appetite, nausea, and abdominal swelling. Fluid often accumulates in the peritoneal space, a condition known as ascites. Over time the wasting symptoms can become more and more severe.
The growing tumor can exert increasing pressure on the organs in the abdomen, leading to bowel obstruction and distention. If the tumor presses upward, it can impair breathing capacity. If the tumor pushes against areas with many nerve fibers, and the bowel distends, the amount of pain can increase.
X-rays and CT scans are, typically, the first step towards detecting peritoneal mesothelioma. The actual diagnosis is typically achieved by obtaining a piece of tissue. The medical procedure of looking at the peritoneum is known as a peritoneoscopy. It is a hospital procedure and requires anesthesia. If an abnormality is seen, the doctor will attempt to obtain a tissue sample - this is known as a biopsy. The tissue sample will be examined by a pathologist who makes a diagnosis using microscopic analysis of specialized stains.
There are at least two explanations for how asbestos fibers can get into the peritoneum. The first is that fibers caught by the mucus of the trachea and bronchi end up being swallowed. Some of them lodge in the intestinal tract and from there they can move through the intestinal wall into the peritoneum. The second explanation is that fibers that lodge in the lungs can move into the lymphatic system and be transported to the peritoneum.
Medical science does not know exactly how or why, at a cellular level, a carcinogen like asbestos causes a cell to become malignant (cancerous.) Thus it is not known whether only one fiber can cause a tumor to develop or whether it takes many fibers, or what the exact conditions and predispositions are for this change to happen.
At this time there are treatments, but no known cure, for peritoneal mesothelioma. The prognosis depends on various factors, including the size and stage of the tumor, its extent, the cell type, and whether or not the tumor responds to treatment.
However, the options for relief and treatment of people with peritoneal mesothelioma have improved, especially for those whose cancer is diagnosed early and treated vigorously. Many people receive a combination of therapies, sometimes known as multimodal therapy. Specific types of treatment include:
There are also clinical trials and various experimental treatments like gene therapy and immunotherapy, and antiangiogenesis drugs.
Pleural mesothelioma
Pleural mesothelioma is of two kinds: (1) diffuse and malignant (cancerous), and (2) localized and benign (non-cancerous.)
Benign mesotheliomas can often be removed surgically, are generally not life-threatening, and are not usually related to asbestos exposure. Malignant mesotheliomas, however, are very serious. Fortunately, they are rare - about two thousand people are diagnosed with mesothelioma in the U.S. each year.
The remainder of this section is about diffuse malignant pleural mesothelioma.
Pleural mesothelioma is a cancer of the cells that make up the pleura or lining around the outside of the lungs and inside of the ribs. Its only known cause in the U.S. is previous exposure to asbestos fibers, including chrysotile, amosite or crocidolite. This exposure is likely to have happened twenty or more years before the disease becomes evident, since it takes many years for the disease to "incubate." It is the most common type of mesothelioma, accounting for about 75% of all cases.
Mesothelioma is sometimes diagnosed by coincidence, before there are any symptoms. For instance, tumors have been discovered through routine chest x-rays. However, when symptoms occur, they may include shortness of breath, weakness, weight loss, loss of appetite, chest pains, lower back pains, persistent coughing, difficulty in swallowing, alone or in combination. An initial medical examination often shows a pleural effusion, which means an accumulation of fluid in the pleural space - the area between the lungs and the chest wall.
The first step in detecting pleural mesothelioma is, typically, a chest x-ray or CT scan. This is often followed by a bronchoscopy, using a viewing scope to look inside the lungs.
The actual diagnosis usually requires obtaining a piece of tissue through a biopsy. This could be a needle biopsy, an open biopsy, or through a tube with a camera (thoracoscopy or chest scope.) If an abnormality is seen through the camera then a tissue sample can be taken at the same time, using the same tube. This is a hospital procedure that requires anesthesia, but is not usually painful. The tissue sample is tested by a pathologist.
Fluid build-up from the pleural effusion can generally be seen on a chest x-ray and heard during a physical examination, but a firm diagnosis of mesothelioma can only be made through a biopsy and pathological testing. This is important because there are also benign pleural effusions and other tumors that have a similar appearance to mesothelioma. Diagnosing mesothelioma can be quite difficult; it requires special lab stains, and much experience in understanding them.
The spread of the tumor over the pleura causes pleural thickening. This can reduce the flexibility of the pleura and encase the lungs in an increasingly restrictive girdle. With the lungs restricted, they get smaller and less functional, and breathing becomes more difficult. At first a person with mesothelioma may be breathless only when he or she exercises, but as lung function drops, he or she can become short of breath even while resting.
The tumor spreads by direct invasion of surrounding tissue. As it spreads inward it can compress the lungs. As the tumor spreads outward it can invade the chest wall and ribs, and this can be extremely painful.
Current medical science does not know exactly how and why, at a cellular level, asbestos fibers cause mesothelial cells to become abnormal (malignant or cancerous.) Thus it is not known whether only one fiber causes the tumor or whether it takes many fibers. It seems that asbestos fibers in the pleura can start a tumor as well as promote its growth; the tumor does not depend on any other processes for its development.
There is as yet no known cure for malignant mesothelioma. The prognosis depends on various factors, including the size and stage of the tumor, the extent of the tumor, the cell type, and whether or not the tumor responds to treatment. The Firm has represented many clients who lived for five to ten years after diagnosis, most of them in good health for a majority of those years. Some mesothelioma victims succumb within a few months; the average survival time is about a year.
The treatment options for people with mesothelioma have improved significantly, especially for those whose cancer is diagnosed early and treated vigorously. Many people are treated with a combination of therapies, sometimes known as multimodal therapy.
Specific types of treatment include:
- » Chemotherapy and other drug-based therapies
- » Radiation therapy
- » Surgery and
- » Intra-operative photodynamic therapy.
There are also experimental treatments like gene therapy and immunotherapy, angiogenesis inhibitors, and clinical trials for various new treatments and combinations of treatments.
Treatments that reduce pain and improve lung function, are becoming more successful (although they cannot cure mesothelioma.) Pain control medications have become easier to administer. Debulking is a surgical process of removing a substantial part of the tumor and reducing the pleural thickening; this can provide significant relief. X-ray therapy has also been successfully used to control the tumor and the pain associated with it for a while.
Treatment Decision Tools
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Mesothelioma !!
The tissue that lines your lungs, stomach, heart and other organs is called mesothelium. Mesothelioma is cancer of that tissue. It is a rare but serious type of cancer. It usually starts in the lungs, but can also start in the abdomen or other organs. Most people who develop mesothelioma have worked on jobs where they inhaled asbestos particles. It can take a long time - 30 to 50 years - between being around asbestos and getting the disease. Treatment includes surgery, radiation, chemotherapy or all three.
National Cancer Institute
- Malignant Mesothelioma (PDQ): Treatment
(National Cancer Institute) Also available in Spanish
- What Is Malignant Mesothelioma?(American Cancer Society)
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- Overviews
- Mesothelioma(Mayo Foundation for Medical Education and Research)
- Mesothelioma: Questions and Answers(National Cancer Institute)
- Diagnosis/Symptoms
- How Is Malignant Mesothelioma Diagnosed?(American Cancer Society)
- How Is Malignant Mesothelioma Staged?(American Cancer Society)
- Treatment
- Chemotherapy for Malignant Mesothelioma(American Cancer Society)
- Pleurodesis(International Mesothelioma Program)
- Radiation Therapy for Malignant Mesothelioma(American Cancer Society)
- Surgery for Malignant Mesothelioma(American Cancer Society)
- Prevention/Screening
- What Are the Risk Factors for Malignant Mesothelioma?(American Cancer Society)
- Disease Management
- Malignant Mesothelioma: What Happens After Treatment?(American Cancer Society)
- Related Issues
- What Should You Ask Your Doctor about Malignant Mesothelioma?(American Cancer Society)
- Clinical Trials
- ClinicalTrials.gov: Mesothelioma(National Institutes of Health)
- ClinicalTrials.gov: Mesothelioma
- Research
- What's New in Malignant Mesothelioma Research and Treatment?(American Cancer Society)
- Journal Articles
References and abstracts from MEDLINE/PubMed (National Library of Medicine)
- Article: Outcomes after extrapleural pneumonectomy and intensity-modulated radiation therapy for malignant...
- Article: Immunohistochemical detection of XIAP in mesothelium and mesothelial lesions.
- Article: Phase II study of vinflunine in malignant pleural mesothelioma.
- Mesothelioma -- see more articles
- Asbestos related mesothelioma -- see more articles
- Dictionaries/Glossaries
- Glossary of Terms(Mesothelioma Applied Research Foundation)
- Organizations
- American Cancer Society
- American Lung Association
- Mesothelioma Applied Research Foundation
- National Cancer Institute
- Statistics
- What Are the Key Statistics about Malignant Mesothelioma?(American Cancer Society)
How Is Malignant Mesothelioma Staged?
Staging is the process of finding out how far the cancer has spread. Staging of mesothelioma is based on imaging studies such as x-rays, CT scans, and MRI scans. The treatment and outlook for patients with mesothelioma largely depends on the stage (extent of spread) of their cancer. Since pleural mesothelioma occurs most frequently and has been studied the most, it is the only mesothelioma for which a staging classification exists.
The major staging system has recently been developed by the International Mesothelioma Interest Group and adopted by the American Joint Committee on Cancer (AJCC). This is a TNM system, similar to staging systems used for most other cancers. T stands for tumor (its size and how far it has spread to nearby organs), N stands for spread to lymph nodes, and M is for metastasis (spread to distant organs). In TNM staging, information about the tumor, lymph nodes, and metastasis is combined in a process called stage grouping to assign a stage described by Roman numerals from I to IV.
T Stages
T1: Mesothelioma involves either the right or left pleura lining the chest. It has only spread to the pleura covering the lung, with the exception of possibly a few other small spots.
T2: Mesothelioma involves either the right or left pleura lining the chest and has spread from the lining of the chest into 1) the outer lining of the lung, 2) the diaphragm, or 3) into the lung itself.
T3: Mesothelioma involves either the right or left pleura lining the chest and has spread into 1) the first layer of the chest wall, 2) the fatty part of the mediastinum, 3) a single place in the chest wall, or 4) the outer covering layer of the heart.
T4: Mesothelioma involves either the right or left pleura lining the chest and has spread 1) into the chest wall, either muscle or ribs, 2) through the diaphragm, 3) into any organ contained in the mediastinum (esophagus, trachea, thymus, blood vessels), 4) into the spine, 5) across to the pleura on the other side of the chest, 6) through the heart lining or into the heart itself, or 7) into the brachial plexus (nerves leading to the arm).
N Stages
N0: No spread to lymph nodes.
N1: Spread to lymph nodes on the same side of the chest as the mesothelioma.
N2: Spread to lymph nodes around the point where the windpipe branches into the left and right bronchi or to lymph nodes in the space behind the chest bone and in front of the heart (mediastinum). Affected lymph nodes are on the same side of the cancerous lung.
N3: Spread to lymph nodes near the collarbone on either side, to hilar or mediastinal lymph nodes on the side opposite the cancerous lung.
M Stages
M0: No spread to distant organs or areas.
M1: The cancer has spread distantly.
Stage Grouping for Pleural Mesothelioma
Once the T, N, and M categories have been assigned, this information is combined (stage grouping) to assign an overall stage of I, II, III, or IV. Patients with lower stage numbers have a better prognosis.
Stage I (T1, N0, M0): Mesothelioma involves either the right or left pleura lining the chest. It has only spread to the outer lining of the lung in, at most, a few small spots. It has not spread to the lymph nodes or distant sites.
Stage II (T2, N0, M0): Mesothelioma involves either the right or left pleura lining the chest and has spread from the lining of the chest into 1) the outer lining of the lung, 2) the diaphragm, or 3) into the lung itself. It has not spread to the lymph nodes or distant sites.
Stage III (T1 or 2, N1 or 2, M0; OR T3, N0-2, M0): Mesothelioma involves either the right or left pleura lining the chest and may or may not have spread from the lining of the chest into 1) the outer lining of the lung, 2) the diaphragm, 3) into the lung itself and has spread to lymph nodes anywhere in the chest on the same side as the tumor, but has not spread to distant sites; OR Mesothelioma involves either the right or left pleura lining the chest and has spread into 1) the first layer of the chest wall, or 2) the fatty part of the mediastinum, or 3) a single place in the chest wall or 4) the outer covering layer of the heart and may or may not have spread to lymph nodes but not as far as to lymph nodes near the collarbone or on the opposite side of the chest. It has not spread to distant sites.
Stage IV (T4, any N, M0; OR any T, N3, M0; OR any T, any N, M1): Mesothelioma involves either the right or left pleura lining the chest and has spread 1) into the chest wall, either muscle or ribs, 2) through the diaphragm, 3) into any organ contained in the mediastinum (esophagus, trachea, thymus, blood vessels), 4) into the spine, 5) across to the pleura on the other side of the chest, 6) through the heart lining or into the heart itself, or 7) into the brachial plexus (nerves leading to the arm), and may or may not have spread to lymph nodes anywhere, but has not spread to distant sites; OR the tumor is of any size, but has spread to lymph nodes near the collarbone on either side, to hilar or mediastinal lymph nodes on the side opposite the cancerous lung but not to distant sites; OR the mesothelioma has spread to distant sites.
Other Prognostic Factors
Although stage is an important factor that determines a patient�s prognosis, other factors should also be considered. Some of these are poor performance status (for example being too sick to perform normal tasks of daily life), chest pain, shortness of breath, weight loss, high levels of a substance in the blood called LDH, low red blood cell count, high white blood cell count and others. These are considered serious factors and most people with all of these factors usually die within 6 months. Few live 2 years. Most people with none of these serious factors will live at least one year and have a 40% chance of living 2 years.src="http://pagead2.googlesyndication.com/pagead/show_ads.js">
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CancerHelp UK is not designed to provide medical advice or professional services and is intended to be for educational use only. The information provided through CancerHelp UK is not a substitute for professional care and should not be used for diagnosing or treating a health problem or a disease. If you have, or suspect you may have, a health problem you should consult your doctor.
Diagnosing mesothelioma
This section tells you about the tests used to diagnose mesothelioma. You can choose from the following menu
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犬惡性間皮細胞瘤
| 一、 | 病歷： | ||||||||||||||||||
| 患犬為一隻體重21.7 kg之混種閹公犬，主訴為外觀消瘦，腹部膨大，呼吸困難及精神沈鬱等症狀，由地方動物醫院轉診至本校教學醫院就診。 | |||||||||||||||||||
| 臨床檢查：經放射線及超音波均發現胸腹腔皆有大量液體蓄積，且於肝、脾臟表面可見圓形或卵圓形疑似腫瘤團塊。投予抗腫瘤藥物無明顯改善。 | |||||||||||||||||||
| 胸、腹水檢查在超音波影像引導下實施胸、腹腔穿刺術，抽取 胸、腹腔內液體進行檢查。胸、腹腔內液體皆為深紅色、血樣、混濁、無臭、不具黏稠性及凝固性，總有核細胞數2.1×103/μl，蛋白質含量0.5 g/dL，比重1.015，為修飾的漏出液（modified transudate）。抹片鏡檢下以紅血球為主，還有少數反應型間皮細胞、吞噬細胞及非退行性白血球。 | |||||||||||||||||||
| 多次抽取血樣胸腹水約800～3500 ml。且進行兩次開腹探測，並於橫膈、腹壁、胃、肝、脾臟及胃網膜可見有多發，直徑0.5-3.0公分，大小不一，表面光滑的圓形或卵圓形疑似腫瘤的團塊。 | |||||||||||||||||||
| 進行生檢，診斷為間皮細胞瘤。最後於治療期間死亡，移送病理診斷。 | |||||||||||||||||||
| 二、 | 肉眼病變： | ||||||||||||||||||
| 該犬外觀消瘦脫水，脂肪呈嚴重漿液性萎縮，背部皮下脂肪消失。胸腔與腹腔中皆有大量 之血樣液體。並可見胸壁，心包囊漿膜面，心外膜及橫膈表面瀰漫性的佈滿白色表面粗糙之小結節。在腹壁、胃、腸系膜、腸系膜淋巴結、肝臟、脾臟、膀胱與左腎 被膜表面，皆可見白色大小不一表面光滑觸感堅實之團塊(圖1,2,3)。其他病變如下： | |||||||||||||||||||
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| 三、 | 組織病變： | ||||||||||||||||||
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| 四、 | 診斷： | ||||||||||||||||||
| 犬惡性間皮細胞瘤(Malignant Mesothelioma in a Dog) | |||||||||||||||||||
| 五、 | 討論： | ||||||||||||||||||
| 間皮細胞瘤在狗貓之發生率約 為千分之一，且十分少見。腫瘤細胞主要侵犯胸腹腔與心包囊，也有侵犯至陰囊之vaginal tunic。依據人的流行病學調查結果，暴露於含石綿之環境中，為致病的重要因素之一，其他如貴橄欖石（chrysolite）、角閃石 （Amphibole）等其他礦物質纖維皆為致癌因子，皆能有效地誘導染色體1、2、3、6、11、17及22重組，導致proto-oncogenes 的活化與tumor suppressor genes的不活化，但詳盡的致病機制仍不清楚。依據Glickman等人於1983年發表的報告中指出，發病的患犬，其畜主可能常工作於石綿環境中，或 是與殺蟲劑的使用，驅蚤劑的污染有關。當巨噬細胞吞噬石綿纖維後，產生之oxygen-free radical會重複的造成tumor precursor cell的基因性傷害，導致化生。經石綿纖維活化之巨噬細胞同時分泌IL-1、FGF（fibroblast growth factor）、PDGF使細胞增殖。 | |||||||||||||||||||
| 組織學上，正常之間皮層為一單 層細胞之間皮細胞。間皮細胞表面含microvilli、desmosome並具有吞噬與分泌的能力。體腔內的炎症與傷害，可使間皮細胞產生明顯的生理性 增殖；體液的蓄積也會造成間皮細胞的脫落與生成。間皮細胞型態為扁平或立方上皮細胞，但由中胚層分化而來。因此間皮細胞瘤可呈現上皮性、纖維性或混合性之 組織型態。間皮細胞瘤因可於體腔內散播，並造成多發之腫瘤生長而視為惡性瘤。 | |||||||||||||||||||
| 典型的間皮細胞瘤為瀰漫性分布於體腔壁上或臟器漿膜面之結節團塊，由於腫瘤表面的分泌物與因腫瘤組織阻塞之淋巴管而造成廣泛性之體液蓄積，常見之臨床症狀為呼吸困難、胸腹水與腹部膨大。若有侵犯至心包囊之間皮細胞瘤則可能伴隨著急性血栓與右心衰竭。 | |||||||||||||||||||
| 在組織型態上，上皮性的主要特 徵為組織長成乳頭狀及管狀的型態，通常主要是立方上皮細胞，其次為扁平型，只有很少數的細胞型態為柱狀上皮細胞；細胞質有單一至多個圓型的細胞質空泡，細 胞核大，核仁也大；細胞表面可見有刷狀緣(adenocarcinoma則是以柱狀為主，且無brush border)。纖維性間皮細胞瘤的細胞型態為卵圓形、長形或紡錘形，同時也如上皮性一般具有vesicular nuclei。 | |||||||||||||||||||
| 在診斷方面，胸腹水之細胞學檢 查無法有效地診斷出間皮細胞瘤，雖然在胸腹水中可見到脫落之間皮細胞，但生理上的增殖與化生卻是難以區分的；其他的檢查如放射線學、超音波、CT或是 MRI皆只是輔助診斷，而直接生檢是最直接診斷的方式。典型的病例以H&E染色配合臨床表現即可確診，否則需要免疫化學染色來幫助確診。 | |||||||||||||||||||
| 六、 | 參考文獻： | ||||||||||||||||||
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Mesothelioma
Original Article:http://www.nlm.nih.gov/medlineplus/mesothelioma.html
Mesothelioma
Introduction
Malignant mesothelioma is a rare cancer that occurs in the thin layer of tissue that covers the majority of your internal organs (mesothelium). Doctors divide mesothelioma into different categories based on what part of the mesothelium is affected by cancer. Mesothelioma that occurs in the tissue that surrounds the lung (pleura) is called pleural mesothelioma and is the most common form. Mesothelioma that occurs in the tissue in your abdomen (peritoneum) is called peritoneal mesothelioma and accounts for 10 percent to 20 percent of all mesotheliomas. In rare cases, mesothelioma can also occur in the lining around the heart (pericardium) and in the lining around the testicles (tunica vaginalis).
Between 2,000 and 3,000 people are diagnosed with mesothelioma in the United States each year. Men are more likely to develop mesothelioma than are women. It's more common in older adults — most people with mesothelioma are 65 and older — though mesothelioma can be diagnosed at any age.
Mesothelioma is closely linked to exposure to asbestos — a natural fiber that was once used in manufacturing a wide variety of industrial and household products. Mesothelioma rates have increased during the past 20 years in response to the widespread use of asbestos in the past. Many industrialized countries now limit asbestos use and enforce laws to protect workers who may be exposed. Researchers predict these efforts will lead to fewer cases of mesothelioma in the future.
Signs and symptoms
Signs and symptoms of mesothelioma vary depending on where the cancer occurs.
Pleural mesothelioma signs and symptoms may include:
* Shortness of breath
* Painful breathing
* Chest pain under the rib cage
* Unusual lumps of tissue under the skin on your chest
* Unexplained weight loss
* Dry (nonproductive) cough
Peritoneal mesothelioma signs and symptoms may include:
* Abdominal pain
* Abdominal swelling
* A change in your bowel habits, such as more frequent diarrhea or constipation
* Lumps of tissue in the abdomen
* Unexplained weight loss
Signs and symptoms of pericardial mesothelioma and mesothelioma of the tunica vaginalis are unclear. These forms are so rare that not much information is available. Mesothelioma of the tunica vaginalis may be first detected as a mass on a testicle. Pericardial mesothelioma signs and symptoms may include difficulty breathing and fever.
Signs and symptoms of mesothelioma that has spread to other parts of the body include:
* Pain in the area where cancer has spread
* Difficulty swallowing
* Swelling in the neck and face
Causes
In general, cancer begins with a genetic mutation that turns normal, healthy cells into abnormal cells. Healthy cells grow and multiply at a set rate, eventually dying at a set time. Abnormal cells grow and multiply out of control, and they don't die. The accumulating abnormal cells form a mass (tumor). Cancer cells invade nearby tissues and can break off from an initial tumor to spread elsewhere in the body (metastasize).
It isn't clear what causes the initial genetic mutation that leads to mesothelioma, though researchers have identified factors that may increase the risk. It's likely that cancers form because of an interaction between many factors, such as inherited conditions, your environment, your health conditions and your lifestyle choices.
Risk factors
Asbestos exposure plays a role in 70 percent to 80 percent of mesothelioma cases, though the actual percentage could be higher. Asbestos is a mineral that is found naturally in the environment. Asbestos fibers are strong and resistant to heat, making them useful in a wide variety of applications. Asbestos fibers have been used to make insulation, cement, brakes, shingles, flooring and many other products.
People who work around asbestos fibers are thought to have the greatest risk of mesothelioma. When asbestos is broken up — for instance, in the mining process or in removing asbestos insulation from a building — dust may be created. If the dust is inhaled or swallowed, the asbestos fibers may settle in the lungs or in the stomach, where they can cause irritation that may lead to mesothelioma, though how exactly this happens isn't understood. Although asbestos is still used in a limited number of industries, the federal government limits the amount of asbestos fibers workers may be exposed to and sets rules to protect workers.
Mesothelioma risk is believed to be increased in people who are exposed to high levels of asbestos, in people who are exposed to asbestos over a long period of time and in people exposed to asbestos at a young age. It can take 30 to 40 years or more for mesothelioma to develop as a result of asbestos exposure.
People who live with workers exposed to asbestos may also have an increased risk of mesothelioma. Asbestos dust is thought to have been carried home on workers' clothes. Today workers are required to shower and change clothes after working with asbestos to protect their families.
Some people with years of asbestos exposure never develop mesothelioma. Researchers estimate only about 5 percent of the people with the highest exposure to asbestos will develop mesothelioma. And yet, others with very brief exposure develop the disease. This indicates that other factors may be involved in determining whether someone gets mesothelioma or doesn't. For instance, you could inherit a predisposition to cancer or some other condition could increase your risk. Risk of mesothelioma is increased greatly in smokers who are exposed to asbestos.
Other possible risk factors
Researchers have identified other factors that may increase the risk of mesothelioma, including:
* SV40. Some research indicates a link between mesothelioma and simian virus 40 (SV40), a virus originally found in monkeys. Millions of people may have been exposed to SV40 when receiving polio vaccinations between 1955 and 1963, because the vaccine was developed using monkey cells. Once it was discovered that SV40 was linked to certain cancers, the virus was removed from the polio vaccine. There is some evidence that SV40 may also be passed between people, though it isn't clear how. Whether SV40 increases the risk of mesothelioma is a point of contention, and more research is needed.
* Radiation. The radioactive substance thorium dioxide was used along with X-rays to diagnose various health conditions from the 1920s to the 1950s. Thorium dioxide was later found to cause cancer and was no longer used. Some research links thorium dioxide to mesothelioma.
* Asbestos-like minerals. A naturally occurring asbestos-like mineral called zeolite has been linked to mesothelioma cases in Turkey, where the mineral is used to construct homes.
* Family history. Research into the same region of Turkey where zeolite is used reveals that family history may play a role in mesothelioma there. More research is needed to determine whether family history may predispose some people to mesothelioma.
When to seek medical advice
See your doctor if you have signs and symptoms that may indicate mesothelioma. Signs and symptoms of mesothelioma aren't specific to this disease and may be related to other conditions. If any signs and symptoms seem unusual or bothersome to you, ask your doctor to check them out.
Screening and diagnosis
If you have signs and symptoms that might indicate mesothelioma, your doctor will conduct a physical exam, paying particular attention to areas where you're experiencing pain. He or she checks for any lumps or other unusual signs. Your doctor may order other tests to determine the cause of your signs and symptoms, including:
* Chest X-ray. X-rays may show abnormalities if you have pleural mesothelioma.
* Chest or abdominal CT scan. Computerized tomography (CT) may reveal abnormalities in your chest or abdomen if you have mesothelioma.
It's not uncommon for mesothelioma to be misdiagnosed initially because mesothelioma is rare and its signs and symptoms aren't specific. Your doctor will likely rule out other more common conditions before considering mesothelioma.
Biopsy
Biopsy, a surgical procedure to remove a small portion of the mesothelium for laboratory examination, is the only way to determine whether you have mesothelioma. Depending on what area of your body is affected, your doctor selects the right biopsy procedure for you. Options include:
* Fine-needle aspiration. The doctor removes fluid or a piece of tissue with a small needle inserted into your chest or abdomen.
* Thoracoscopy. Thoracoscopy allows the surgeon to see inside your chest. In this procedure, the surgeon makes one or more small incisions between your ribs. He or she inserts a tube with a tiny video camera to see inside your chest cavity — a procedure sometimes called video-assisted thoracoscopic surgery (VATS). Special surgical tools allow your surgeon to cut away a piece of tissue.
* Laparoscopy. Laparoscopy allows the surgeon to see inside your abdomen. Using one or more incisions into your abdomen, the surgeon inserts a tiny camera and special surgical tools to obtain a small piece of tissue for examination.
* Thoracotomy. Thoracotomy is surgery to open your chest to allow a surgeon to check for signs of disease. He or she removes a sample of tissue for testing.
* Laparotomy. Laparotomy is surgery to open your abdomen to allow a surgeon to check for signs of disease. He or she removes a sample of tissue for testing.
Once the tissue sample has been collected through biopsy, the sample is analyzed under a microscope. This determines whether or not the abnormal tissue is mesothelioma. Biopsy samples also allow your doctor to test for the type of cells involved in your mesothelioma. The type of mesothelioma you have is used to determine your treatment plan.
Staging
Once mesothelioma is diagnosed, your doctor orders other tests to determine the extent of the cancer and whether it has spread — a process called staging. Imaging procedures allow doctors to see inside your chest or abdomen to determine the stage of mesothelioma. Options include:
* Chest X-ray
* CT scans of the chest and abdomen
* Magnetic resonance imaging (MRI)
* Positron emission tomography (PET)
Once the extent of mesothelioma is determined, a stage is assigned. Staging helps your doctor determine your prognosis and the best treatment plan. The stages of mesothelioma are:
* I. Stage I mesothelioma is considered localized cancer, meaning it's limited to one small area of the chest or abdomen.
* II. Stage II mesothelioma is considered advanced cancer. Mesothelioma at this stage involves the mesothelium and has also spread to other structures directly adjacent to the tumor, such as the lungs or the diaphragm.
* III. Stage III mesothelioma is also considered advanced cancer. Mesothelioma at this stage meets the same requirements as stage II, but has also spread to the lymph nodes in the region.
* IV. Stage IV mesothelioma is an advanced cancer that has spread to distant areas (metastasized). Mesothelioma most commonly spreads (metastasizes) to the brain and areas of the lung that are away from the tumor.
Complications
As pleural mesothelioma spreads in the chest, it puts pressure on the structures in that area. This can cause complications, such as:
* Difficulty breathing
* Chest pain
* Difficulty swallowing
* Swelling caused by pressure on the large vein that leads from your upper body to your heart (superior vena cava syndrome)
* Pain caused by pressure on the nerves and spinal cord
Mesothelioma that progresses can lead to death. People who die of mesothelioma usually die from related complications, such as lung failure, bowel obstruction, heart problems, stroke and other causes.
Treatment
What treatment you undergo for mesothelioma depends on your health and certain aspects of your cancer, such as its stage and location. Unfortunately, mesothelioma often is an aggressive disease and for many people a cure won't be possible. Mesothelioma is usually diagnosed at an advanced stage — when it isn't possible to remove the cancer through surgery. Instead, your doctor may work to control your cancer and its signs and symptoms to make you more comfortable.
Discuss your treatment goals with your doctor. Some people want to do everything they can to treat their cancer, even if that means enduring side effects for a small chance of a cure. Others prefer treatments that make them comfortable so that they can live their remaining months as symptom-free as possible.
Mesothelioma treatment options may include surgery, radiation, chemotherapy and clinical trials.
Surgery
Surgeons work to remove mesothelioma from your body. Sometimes it isn't possible to remove all of the cancer. In those cases, surgery may help to reduce the signs and symptoms caused by mesothelioma spreading in your body. Surgical options may include:
* Surgery to decrease fluid buildup. Pleural mesothelioma may cause fluid to build up in your chest, causing difficulty breathing. Surgeons insert a tube or catheter into your chest to drain the fluid. Surgeons may also inject medicine into your chest to prevent fluid from returning (pleurodesis).
* Surgery to remove the tissue around the lung or abdomen. Surgeons may use scalpels and other surgical tools to remove the tissue lining the ribs and the lungs (pleurectomy) or the tissue lining the abdominal cavity (peritonectomy) in order to relieve signs and symptoms of mesothelioma.
* Surgery to remove as much of the cancer as possible (debulking). If all of the cancer can't be removed, surgeons may attempt to remove as much as possible.
* Surgery to remove a lung and the surrounding tissue. Removing the affected lung and the tissue that surrounds it may relieve signs and symptoms of pleural mesothelioma. This procedure also allows doctors to use higher doses of radiation against any remaining mesothelioma, since doctors won't need to worry about protecting your lung from damaging radiation.
Chemotherapy
Chemotherapy uses chemicals to kill cancer cells. Chemotherapy drugs travel throughout your body and kill rapidly growing cells. This works against cancer cells, but also affects other rapidly growing cells in your body, such as those in your hair follicles and those in your gastrointestinal system. Chemotherapy may slow the growth of pleural mesothelioma. Chemotherapy can be used before surgery (neoadjuvant chemotherapy) or after surgery (adjuvant chemotherapy) to reduce the signs and symptoms you may experience from mesothelioma.
People with peritoneal mesothelioma may receive adjuvant chemotherapy drugs that have been heated (hyperthermic chemotherapy). Rather than being distributed throughout the body, chemotherapy drugs are often injected directly into the abdominal cavity (intraperitoneal chemotherapy), where they can reach the peritoneal mesothelioma directly without injuring healthy cells in other parts of the body. This allows doctors to administer higher doses of chemotherapy drugs. Intraperitoneal chemotherapy may also be used to reduce the signs and symptoms of peritoneal mesothelioma that can't be removed through surgery.
Radiation therapy
Radiation therapy focuses high-energy radiation to a specific spot or spots on your body. Radiation may reduce signs and symptoms in people with pleural mesothelioma. Doctors aim radiation at the entire chest to obtain the best result. However, many sensitive organs reside in the chest, such as the heart, lungs and spinal cord, so doctors must use low doses of radiation to spare these organs. Radiation therapy is sometimes used after biopsy or surgery to prevent mesothelioma from spreading to the surgical incision.
Radiation therapy is used occasionally in people with peritoneal mesothelioma. Radiation may reduce signs and symptoms of mesothelioma.
Combination therapy
Surgery, chemotherapy and radiation therapy may be combined. This aggressive therapy can be grueling and may not be appropriate for everyone. Younger, healthier people and those with earlier stage mesothelioma may be more able to endure this treatment. Combination therapy has shown the most promise in treating mesothelioma. However, most people will eventually experience a recurrence of this cancer despite this aggressive treatment. Combination therapy has been used in both pleural mesothelioma and peritoneal mesothelioma.
Clinical trials
Clinical trials are studies of new mesothelioma treatment methods. People with mesothelioma may opt for a clinical trial for a chance to try new types of treatment. However, a cure isn't guaranteed. Carefully consider your treatment options and talk to your doctor about what clinical trials are open to you. Your participation in a clinical trial may help doctors better understand how to treat mesothelioma in the future.
Treatment for other types of mesothelioma
Pericardial mesothelioma and mesothelioma of the tunica vaginalis are very rare and can be very aggressive. Early-stage cancer may be removed through surgery. Doctors have yet to determine the best way to treat later stage cancers, though. Your doctor may recommend other treatments to improve your quality of life.
Prevention
Reducing your exposure to asbestos may reduce your risk of mesothelioma. Most people with mesothelioma were exposed to the asbestos fibers at work. Workers who may encounter asbestos fibers include:
* Miners
* Factory workers
* Insulation manufacturers
* Railroad workers
* Ship builders
* Gas mask manufacturers
* Construction workers
Follow all safety precautions in your workplace, such as wearing protective equipment. You may also be required to shower and change out of your work clothes before taking a lunch break or going home. Talk to your doctor about other precautions you can take to protect yourself from asbestos exposure.
Older homes and buildings may contain asbestos. In many cases, it's more dangerous to remove the asbestos than it is to leave it intact. Breaking up asbestos may cause fibers to become airborne, where they can be taken into your body as you breathe. Consult experts trained to detect asbestos in your home. These experts may test the air in your home to determine whether the asbestos is a risk to your health. Don't attempt to remove asbestos from your home — hire a qualified expert.
Coping skills
Shock. Anger. Sadness. Despair. Confusion. You may be feeling one or all of these emotions after receiving a mesothelioma diagnosis. A cancer diagnosis is devastating not only to you, but to your family and loved ones. Take time to experience the sadness and despair and to grieve. As you're shuffled between appointments with various doctors and specialists, know that you can take control of the time you have remaining. You decide how you'll spend your time and whom you'll spend your time with. Along with your doctor, you determine which treatments you'll undergo.
In order to regain a sense of control, try to:
* Learn everything you can about mesothelioma. Write down a list of questions to ask your doctor. Ask your health care team for reading materials and other resources to help you better understand your disease. Consult the National Cancer Institute (NCI) and the American Cancer Society (ACS) for more information. Both organizations can provide you with information through their Web sites or toll-free telephone information lines. Call the NCI at 800-4-CANCER, or 800-422-6237. Call the ACS at 800-ACS-2345, or 800-227-2345. Information may help you feel more confident in your treatment decisions, and it may help you better understand what's going on inside your body.
* Surround yourself with a support network. Whether it's close friends or family or a combination of both, surround yourself with people who love you. These people can help you with the everyday tasks, such as getting you to appointments or treatment, and they can help support you by providing someone to talk to or to reassure you. If you have trouble asking for help, learn to be honest with yourself and accept help when you need it — your friends and family feel helpless too, and they want to help you.
* Seek out other people with cancer. Ask your health care team about cancer support groups in your community. Sometimes there are questions that can only be answered by other people with cancer. Support groups offer a chance to ask these questions and receive support from people who understand your situation. Online support message boards can offer similar benefits while allowing you to remain anonymous.
* Plan for the unknown. Ask your health care team about advance directives that give your family guidance on your medical wishes in case you can no longer speak for yourself. Talk to a lawyer about your will, if you haven't already done so.
By Mayo Clinic Staff
Aug 11, 2006
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