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 •

Case History  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.

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 Investigations Abdomen Pelvis: Pleural based mass noted • on 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 •

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

 Combination chemotherapy Treatment 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

 Chemotherapy well tolerated ,  Subjective improvement in respiratory chemotherapy Post 3 cycles 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

3 months later….  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

 Is histological subtype (i.e sarcomatoid vs non-saromatoid) a predictive variable? Discussion  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 2 nd line chemotherapy? Is there a preferred cytotoxic agent?

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