Surgery
Mesothelioma surgery can be aggressive, long-term control surgery or palliative procedures to relieve symptoms. Before surgery, a patient is tested to make sure that no cancer has spread to distant sites and to evaluate heart and lung function. Lung function is often compromised in patients with pleural mesothelioma due to compression of the lung, decrease function due to age, or a history of smoking cigarettes.

One type of aggressive surgery is an extrapleural pneumonectomy involving removal of the pleura, the lung, the diaphragm and the pericardium. The intent is to remove as much of the tumor as possible. Not all centers will perform this procedure because of its complexity and because it carries a high risk of death within 30 days after surgery. Extrapleural pneumonectomy typically is performed only in younger patients in good overall health with Stage I disease.

A pleurectomy can also be performed in select patients, which allows the thick fibrous "peel" to be stripped away, allowing the lung to expand.

Radiation Therapy
Radiation therapy uses high-energy x-rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes in the area where the cancer cells are found (internal radiation therapy). If fluid has collected in the chest or abdomen, the doctor may drain the fluid out of the body by putting a needle into the chest or abdomen and using gentle suction to remove the fluid. If fluid is removed from the chest, it is called thoracentesis. If fluid is removed from the abdomen, it is called paracentesis. The doctor may also put drugs through a tube into the chest to prevent more fluid from accumulating.

Because of the location of malignant mesothelioma, it is extremely difficult to deliver high enough doses of radiation to kill the tumor without damaging the surrounding organs. Lower doses of radiation can result in some reduction in the disease, but it is unclear whether this reduction actually results in longer survival than no treatment.
 
Using radiation therapy after surgery has not been shown to improve survival. However, because surgery is very unlikely to remove the entire tumor, radiation commonly is administered after surgery in the hopes of killing remaining tumor cells. In addition, radiation therapy can be used to relieve symptoms of mesothelioma, including chest pain.

Chemotherapy
Chemotherapy uses medication to kill cancer cells. It can be taken in pill form or it may be put into the body by a needle in the vein or muscle. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells throughout the body. In mesothelioma, chemotherapy may be put directly into the chest (intrapleural chemotherapy). Like radiation therapy, chemotherapy may be administered after surgery in an attempt to kill cancer cells that could not be removed during the procedure.

The use of medications to treat cancer has had disappointing results in the treatment of malignant mesothelioma. Some chemotherapy drugs have a partial effect in some patients. Combination chemotherapy (using more than one drug at the same time) may be given in an attempt to improve response. There are many new medications and medication combinations being tried in ongoing trials. Some of these combinations have shown promise and there is hope for the future.

Palliative (Pain Reduction) Procedures
When malignant mesothelioma is advanced, palliative procedures can be performed to relieve and/or control symptoms such as breathlessness, which are caused by effusion (fluid collection) or by the tumor compressing the lung or other organs. These procedures do not aim to cure the disease.

• Thoracentesis can be used to treat effusion in pleural mesothelioma. A needle is inserted into the chest to drain the fluid, relieving breathlessness and pain. Talc may be introduced into the pleura to limit recurrence of the effusion. Similar procedures are used to treat ascites (fluid collection) in peritoneal mesothelioma.
   
• Pleurectomy/decortication is the surgical removal of the pleura. This procedure can be performed to reduce pain caused by the tumor mass or to prevent the recurrence of pleural effusion. For peritoneal mesothelioma, surgery generally is aimed at relieving symptoms, such as recurrent ascites or bowel obstruction. As with pleural mesothelioma, complete surgical removal of the entire tumor is unlikely.

Treatment by Stage
Pleural mesothelioma can be treated according to stage. Currently, there are no standard treatment options by stage for peritoneal mesothelioma.

• Stage I (localized) mesothelioma — If a patient wants aggressive treatment and is deemed fit to undergo surgery, some centers may perform an extrapleural pneumonectomy. Another surgical option is pleurectomy/decortication, which is sometimes performed to alleviate some of the symptoms of mesothelioma. Both of these procedures may be followed by radiation therapy or chemotherapy.
   
• Stages II, III and IV (advanced) mesothelioma — Pleurectomy/decortication may be performed to relieve symptoms in pleural mesothelioma. Other procedures such as thoracentesis may be performed to drain pleural effusions and prevent them from recurring. Radiation therapy and/or chemotherapy also may be administered for symptom relief.
   
• Recurrent malignant mesothelioma — There is no standard treatment for recurrent mesothelioma. Generally, treatments are considered that were not used in the first treatment attempt.

Clinical Trials and Future Treatments
New treatments and possible vaccines for malignant mesothelioma are being evaluated in clinical trials, and the future holds some promise. Clinical trials are research studies that evaluate new treatments for safety and effectiveness. There are no guarantees that a new treatment will work, and there are some risks. However, a clinical trial is not undertaken unless the researchers believe the treatment may have some value. Some of the treatments for malignant mesothelioma that are being evaluated include:

• Combination chemotherapy — Different combinations of chemotherapy drugs have been tried with mixed results. A recent study showed some benefit of combining cisplatin (Platinol) and gemcitabine (Gemzar). The researchers used the combination to treat 21 patients with advanced mesothelioma, of whom 47 percent showed a partial response.
   
• Intracavitary chemotherapy — Instilling chemotherapy drugs directly into the pleural or peritoneal space is being researched because of its advantage over traditional chemotherapy. Because the drug is instilled directly into the cavity, much greater doses can be given to patients without causing severe side effects. Some studies have shown this therapy to result in control of effusions and reduced tumor size
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• Brachy therapy (intracavitary radiation therapy) — In this treatment, a radioactive substance is placed directly into the pleural or peritoneal space.
   
• Multimodality therapy — Any combination of surgery, radiation therapy and chemotherapy is multimodality therapy. For example, researchers have combined surgery with intracavitary radiation or chemotherapy and then administered radiation or chemotherapy afterward.
   
• Gene therapy — In this approach, a virus that has been genetically altered is introduced into the tumor. The virus infects the tumor cells and makes them vulnerable to anticancer drugs.
   
• Immunotherapy — Treatments that stimulate the body's immune system to fight cancer cells are called immunotherapy.
   
• Photodynamic therapy — With photodynamic therapy, drugs that are sensitive to light are taken up by the tumor cells, which are then exposed to light.
   
• Intraoperative photodynamic therapy – This is a new type of treatment that uses special drugs and light to kill cancer cells during surgery. A drug that makes cancer cells more sensitive to light is injected into a vein several days before surgery. During surgery to remove as much of the cancer as possible, a special light is used to shine on the pleura. This treatment is being studied for early stages of mesothelioma in the chest.