Trimodality therapy for pleural mesothelioma includes a combination of induction chemotherapy, radical surgery (also called cytoreductive surgery) and radical radiation therapy. The aim of the three phases is to remove as much pleural mesothelioma as possible, stop any remaining mesothelioma cells from growing or spreading, and prolong disease-free living.
The benefits of trimodality therapy for pleural mesothelioma are not yet clear. Not all mesothelioma specialists recommend trimodality therapy, and it’s available only in a few specialist centres. There has not yet been an evidence-based trial comparing the results of trimodality treatment to less intensive treatment.
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The three phases of trimodality therapy
- Induction chemotherapy phase – Three cycles of chemotherapy are given to shrink the tumour. A scan then checks the size of the tumour. If it has been reduced, you will have a rest for 4–6 weeks before having surgery. If there is little or no response, you will not have radical surgery.
- Radical surgery phase – The surgery is usually an extrapleural pneumonectomy (EPP). It removes the affected lung as well as parts of the lining of the heart (pericardium), lining of the chest (parietal pleura) and diaphragm. Lymph nodes in the centre of the chest that drain the lung are also removed. Mesh is used to repair the pericardium and diaphragm. You’ll stay in hospital for 10–14 days, or longer if complications occur. Once at home, recovery can take 6–8 weeks and then you’ll be able to start radiotherapy.
- Radical radiation therapy phase – This phase aims to treat the tumour cells that may still be present. Radiation therapy is delivered using intensity-modulated radiation therapy (IMRT). This type of radiation therapy can be accurately shaped around the chest cavity to allow higher doses to be delivered directly to the tumour cells while minimising the damage to other organs in the chest and abdomen. You will have treatment every day, Monday to Friday, for up to six weeks. The side effects of radiation therapy usually become more intense as treatment progresses. Most people start to feel better 2–3 weeks after treatment ends.
Who can have trimodality therapy
Only a small number of people with pleural mesothelioma have trimodality therapy each year as it is only suitable for people:
- with a small amount of pleural mesothelioma at an early stage (T1–T3)
- with an epithelioid type of pleural mesothelioma
- whose scans show a good response to chemotherapy before surgery and no signs of pleural mesothelioma progression
- with no signs of spread into the lymph nodes or any other disease on CT and/or FDG-PET scans
- who are able to live independently with one lung
- who are physically fit enough for surgery.
The best person to determine if you will be a suitable candidate for this treatment is the surgeon who would perform the surgery.
It is important to ask your surgeon, oncologist and nurse to explain the likely outcome of the surgery for you. An EPP is a major operation, and not everyone wants to go ahead after the risks, benefits and implications of the therapy are explained by their treatment team.
Sometimes, despite a person appearing suitable at first, the doctor may decide it is best for them not to continue with trimodality therapy. This might be because:
- the mesothelioma does not respond well to the chemotherapy
- tests of specimens taken at surgery show that the cancer is growing quickly or has spread
- the person has become too tired or unwell.