Mesothelioma Dr Presha Bipath Registrar: Radiation Oncology Greys - - PowerPoint PPT Presentation

Mesothelioma

Dr Presha Bipath Registrar: Radiation Oncology Greys Hospital, Pietermaritzburg University of KwaZulu-Natal

Case History

 A 62 year old female  A 4/12 duration of :

• Persistent pleuritic chest pain and shortness of breath
• Weight loss
• Loss of appetite
• Productive cough, no haemoptysis

 Past medical history : nil  Past surgical history: nil  Social history : non smoker, sober habits  Occupational history: previously employed in the

textile industry, no history of asbestos exposure.

Case History

Examination findings

 Well looking  ECOG PS 1  Sats:95% on room air  No respiratory distress

• Decreased air entry and stony dullness in the

left lower lobe

• No tracheal shift
• Systemic exam : unremarkable

Investigations

Chest x-ray:

 Tracheal deviation  Blunting of left

costophrenic angle

CT Chest Abdomen Pelvis:

• Pleural based mass noted
• n the left lobe with

lobulated pleural effusion, possible emphysematous changes, interlobar fissure thickening

• No distant metastases.
• Associated mediastinal

adenopathy, largest 1.3 cm

Investigations

Pleural fluid aspirate:

 Chemistry :

Protein :36 Albumin : 23 LDH : 1599

 TB Culture Negative, no bacterial growth  Cytology :

Smears consist of scattered lymphocytes, histiocytes and reactive mesothelial cells seen. No evidence of malignancy.

Investigations

Blood investigations:

 WCC 9,4/ HB : 15,5 PLT : 512  Urea and electrolytes : NAD  Liver function test: TP:76 ALB :40

bil :10

 ALP : 112 AST : 51 GGT :76 LDH :191

Investigations

 A thoracoscopy and VATS biopsy and chemical pleurodesis

was performed.

 Histology :

• Incision biopsy of Left lung: invasive malignant

mesothelioma.

• Immunopositivity: Nuclear WT1, CK5/6, Calretinin and focal

D240.

• Immunonegative for CEA, BerEP4 and p63
• No FISH done

Investigations

Assessment

• Malignant mesothelioma
• Stage: cT4N2M0 (stage IV), Irresectable,
• ECOG PS satisfactory

Treatment

• Combination chemotherapy
• Cisplatin 80mg/m2 day 1 + Gemcitabine

1000mg/m2 day 1; day 8; day 15, q3/52 for 6 cycles

 Note : Unable to obtain Pemetrexed due to resource

constraints

Post 3 cycles chemotherapy

 Chemotherapy well tolerated ,  Subjective improvement in respiratory

symptoms

 Chest x-ray : stable disease at cycle 3  Chemotherapy continued to cycle 6  Restaging CT Scan (post 6 cycles):

Stable disease

Plan: Surveillance

However 3 Months later patient presented with Loss of weight , loss of appetite and worsening respiratory symptoms

• Marked progression of

pleural based mass with almost complete destruction of the left lung

• Diffuse contralateral

pulmonary metastasis

• Epigastric metastatic

lymph node

 Assessment: Disease progression  PS : ECOG 2  Not a candidate for palliative surgery  Patient offered second line chemotherapy :

single agent Vinorelbine

 Vinorelbine 60mg day 1, day 8 p.o q3/52  Dietetics referral

3 months later….

 At cycle 3 patient noted to have tolerated

chemotherapy well

 Patient defaulted post cycle 3  Family contacted 6 weeks later to follow up and we

were informed that patient demised

3 months later….

Discussion

 Is histological subtype (i.e sarcomatoid vs non-saromatoid) a

predictive variable?

 Should a PET-CT have been done for better assessment of

disease – what is the role of PET-CT in mesothelioma ?

 In the setting of non availability of standard of care drugs – what

is an acceptable alternative ?

 What is the role of 2nd line chemotherapy? Is there a preferred

cytotoxic agent?

Thank You!

Dr Presha Bipath Registrar: Radiation Oncology Greys Hospital, Pietermaritzburg University of KwaZulu-Natal