The first sign of pleural mesothelioma “is anxiety”. An insidious disease, it is considered a rare tumor “and we understand why if we compare it to the numbers of lung cancer”, but it poses several problems. First, why “it is common” for the patient to discover it when it is in an advanced stage. Prevention, early diagnosis, “is a problem. For those exposed” to the main risk factor which is asbestos “there is still no clear indication to carry out screening, even if we go a little further towards that direction”.
In more than one case out of two, among other things, this exposure is linked to work reasons. The future? Lights and shadows. The path for patients remains complex and the prognosis is generally not very good. But “research continues”, it is a “transition phase” in which the strategy against this neoplasm is changing. “And an interesting epidemiological fact is that, with occupational exposure to asbestos which today has fortunately been greatly reduced” after this 'killer fibre' was banned, “in recent years the incidence curve has begun a reduction phase”. Giulia Veronesi, professor of thoracic surgery, Vita-Salute University and Irccs San Raffaele hospital in Milan, outlines the picture for Adnkronos Salute.
The expert has been dealing with this pathology for years, on which she is also conducting research, and underlines the importance of maintaining high attention. The journalist Franco Di Mare brought the spotlight back on by reporting on her illness, also trying to answer the question 'why me'. Long a war correspondent in the Balkans, he thought back to those days, to the destructive capacity of the “depleted uranium projectiles”, to the buildings that crumbled, to the explosions that released enormous quantities of dust into the air. In this dust there could also have been asbestos particles. An invisible enemy that presents the bill several years later, even 20-30.
How the disease arises
Mesothelioma, explains Veronesi, “arises from a serosa which is the pleura, a membrane that covers the lungs. And it is a tumor that unfortunately begins as a widespread one, as a disease that substantially extends to the entire pleura. So it is a structure that is difficult to eradicate with surgery. The operation is very complex. Until now it was part of the therapeutic program for this disease, but lately there have been doubts whether to carry it out or not and the latest news in this field suggests that it is better to treat it with chemotherapy. The onset, one of the main symptoms felt by the patient, is often breathlessness due to a pleural effusion, therefore the liquid in the pleural cavity which accumulates and crushes the lung”.
“The expected cases of mesothelioma in Italy are approximately 1,500 in men and 500 in women. And if you look at the trend curves, we have reached the plateau and we are in a small downward phase of the incidence”. For the diagnosis, explains Giulia Veronesi, “a pleural biopsy is performed with a small incision, a thoracoscopy. The extent of the disease is assessed with a chest CT scan and a PET scan. And it can go from a very initial stage, with involvement only of the parietal pleura, and not that which lines the lung, to reach stage 3 or 4 with a disease that infiltrates the lung and the other organs of the chest wall.
Sometimes the first sign is pleural effusion and it can appear early when the disease is still quite limited. However, if for example there is also chest pain, it may mean that the wall has been infiltrated. Furthermore, pleural effusion is often not easily detected. Also because, if the patient is also a smoker and feels a little short of breath, he does not do the tests immediately. The reality is that diagnosis in stage 1 is quite rarethe more frequently we are faced with a disease in a more advanced stage.”
There are various forms of mesothelioma, continues the expert. “The least aggressive is the epithelial one, then there is a form called biphasic and finally the sarcomatoid one. The latter two are more aggressive, they go faster. The epithelial one can also have a fairly slow course. The average survival, without treatments, is around 1-2 years, so it's not very favorable. Chemotherapy gives an advantage in survival and also in quality of life. And for some cases there is also the weapon of immunotherapy. Surgery had a fairly important role in stage 1, when there are no affected lymph nodes and the disease is limited. Today it's a bit up for debate. The operation is a pleurectomy/decortication, that is, the pleura is removed and the entire thoracic cavity is cleaned.”
So what is the role of surgeons today? “Beyond the attempt to carry out radical surgery – describes Veronesi – we deal with making the diagnosis and reducing the problem of the effusion with a small operation called talcum powdering of the pleural cavity. We put sterile talc in thoracoscopy through a hole by a centimeter and at least we reduce the breathing problem because, by eliminating the pleural fluid, we make the visceral pleura attach to the parietal pleura and there is no more space for the fluid to accumulate. So there is a quality of life advantage However, research into new drugs continues. New molecules are also being studied in phase 1which are combined with more traditional treatments”.
And the epidemiological aspect linked to the “reduction of occupational exposure is positive, because asbestos has no longer been used in industry since the beginning of the 90s”, reasons Giulia Veronesi. The impact of this stop can be seen now “because there is a latency of about 20 years from exposure to the substance to the creation of the first tumor cells and then to the clinical onset of the tumor. We can say that more than 50% of mesotheliomas they are due to occupational exposure. However, there are some cases – he points out – in which there is no clear exposure. And we must find other causes. Cigarette smoking can also cause mesothelioma. With Inail we are carrying out a study to evaluate how to make an early diagnosis of mesothelioma even with low-dose CT scans.”
“Prevention is really a problem today – highlights the expert – because anyway it is a rare tumor and for those exposed there is still no clear indication to have a screening CT scan. Once upon a time, surveillance was mainly done with a chest x-ray, but today we are moving more towards a low-dose chest CT scan, like that for lung screening. Then there are a series of studies underway also on molecular markers that can more or less be prognostic indicators, or even diagnostic ones, but we are still in a research phase. An evaluation is certainly underway on what has been the standard up to now – i.e. chemotherapy-surgery-subsequent radiotherapy – in light of new data which is causing radical surgery to lose space. Then there are some new research on radiotherapyand we are trying to push more on new radiotherapy programs with very advanced technologies and machines that try to spare the many surrounding healthy tissues”.
Research, concludes Veronesi, “must be financed. But the problem is also that, being a rare tumor, it is more difficult” to achieve critical mass, “you have few cases to enroll even for experimentation with new drugs. As for funds, there is specific funding for rare tumors, but it is very little. So research must certainly be implemented because it is true that the curve of new cases is decreasing, but very slowly. And there are also cases of familiarity or linked to other carcinogens that are not asbestos, and those numbers are not going down.”
Pneumologists: “Hopes from immunotherapy”
Mesothelioma, confirms to Adnkronos Salute Carlo Vancheri, past president of the Italian Society of Pneumology and full professor of Respiratory Diseases at the University of Catania, “still remains a difficult neoplasm to treat, there are studies and research but what we need to focus on is prevention because in most cases we know the cause. And the courage shown by the journalist Franco Di Mare goes in this direction.” On the treatment front, “there are studies on immunotherapy drugs that are demonstrating effectiveness in prolonging survival with good efficacy of patients affected by other neoplasms that attack the lungs, but a little less, unfortunately, in the case of mesothelioma. However, we are in years in which oncology research is making enormous progress and we must have hope”, recalls Vancheri.
“Being a tumor linked to exposure to asbestos, above all, we know where to start and this should allow us to carry out prevention work especially in work environments – the expert remarks – The scientific community and society must be united in this work”.
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