Surgical Approach to Mesothelioma with David J. Sugarbaker, MD

David J. Sugarbaker, MD, a world-renowned expert in the diagnosis and treatment of pleural malignant mesothelioma, will discuss surgical approaches used currently in treating mesothelioma.

Event_Moderator Welcome to WebMD Live. Today we will be discussing "Surgical Approach to Mesothelioma," with David Sugarbaker, M.D.

David J. Sugarbaker, M.D., is a world-renowned expert in the diagnosis and treatment of pleural malignant mesothelioma, a rare lung cancer that is often the result of asbestos exposure. He pioneered the Brigham Staging System, a way of determining a patient's disease stage. Sugarbaker is a professor of surgery at Harvard Medical School and chief of the department of surgical services at the Dana Farber Cancer Institute in Boston. In addition, Sugarbaker serves as vice-chairman of the department of surgery and chief of the division of thoracic surgery at Brigham and Women's Hospital in Boston. A graduate of Cornell University Medical College, Sugarbaker did his residency in surgery at Brigham and Women's Hospital.

If you would like to ask Dr. Sugarbaker a question, please type /ask followed by your question.

Dr. Sugarbaker, welcome to WebMD Live.

Dr_Sugarbaker  Thank you

Event_Moderator {question presented} What is Mesothelioma?

Dr_Sugarbaker Mesothelioma is a tumor that arises in the cells of the lining of the lung, a covering on the lung. This covering is a shiny surface, which, in the normal state, helps to allow the lung to slide smoothly against the chest wall. These cells are called 'mesothelial' cells. So, when they become abnormal and cancerous, it's called a 'mesothelioma' and it's not a tumor of the lung tissue itself.

Event_Moderator {question presented} How do you get Mesothelioma?

Dr_Sugarbaker Well, there are a number of theories, but the best correlation is exposure to asbestos, specific types, that are inhaled by the individual. And, they settle in the lung and migrate or move out to the surface of the lung where they cause a constant irritation, which, after about 20 years, results in this tumor being produced. So asbestos exposure is thought to represent the primary cause for this disease. There are other far less common causes such as radiation treatments and also what we call 'spontaneous mesothelioma' seen in young adolescents, but these are extremely rare.

Event_Moderator Say someone finds that after 20 years of living in his or her home, they have asbestos. What should they do at that point?

Dr_Sugarbaker Well, the appropriate removal of asbestos is best done by professionals and should be done by companies certified to remove asbestos in a safe way. If asbestos insulation has been found, one can have it contained by a company that comes in to seal it up or one can have it removed.

Event_Moderator What about the theory that one should leave it as to not create asbestos dust?

Dr_Sugarbaker There's no question that the dust is worse, so if it's in the home and can be contained with tape or a sealant that the experts use, then that's an alternative that the expert can make a recommendation about. But if there are children in the home, it should be dealt with so that we don't have it disturbed with unknowingly. I had a 16-year-old patient who was exposed as a baby in a bassinet, where her mother, in the washroom, would shake out her father's clothes that contained asbestos from a shipyard, so she got mesothelioma when she was 16. So, those kinds of exposures are really the most troublesome.

Event_Moderator {question presented} How many people are battling the illness?

Dr_Sugarbaker Well, it is comparatively speaking, a rather rare tumor in the U.S.. There are approximately 4,000 new cases every year. And, this compares to 170,000 new cases of lung cancer or 13,000 new cases of esophageal cancer. However, in Europe, there is an epidemic of mesothelioma because of the much wider use of asbestos in European building construction.

Event_Moderator How is the European medical community equipped to deal with that?

Dr_Sugarbaker There has been a rather nihilistic approach to the disease because of the fact that most patients who contract the disease die within 6 to 18 months. So there has been a defeatist approach because of the very aggressive and recalcitrant nature of this tumor, so many in Europe and Britain have more or less resigned that the patients will not survive, and therapy, many times, is only supportive.

Event_Moderator {question presented} Are there different types of asbestos exposure?

Dr_Sugarbaker There are different types of fibers and they have a different molecular structure .. some of them are more likely to cause mesothelioma than others. For instance, the Canadian asbestos mines have been very prone to the development of mesothelioma in their workers because of the type of asbestos fibers coming out of those mines. The same is true for Australia and South Africa.

Event_Moderator What about the U.S.?

Dr_Sugarbaker Well, the US has had only a small amount of asbestos mines, but most asbestos used in WWII, particularly on the boilers of ships and construction, was imported from Canada. It wasn't until the late 70's that the federal government prohibited the use of asbestos in construction, but this was still well ahead of the European nations.

Event_Moderator {question presented} How long would you have to be exposed to asbestos to be threatened?

Dr_Sugarbaker There is no clear answer to that question because patients have reported extremely brief one day exposures, as well as multiple everyday exposures in an occupation such as ship building, and yet both develop mesothelioma. It appears, however, that the greater the exposure over the course of time, and the amount of asbestos, the greater the chance of contracting mesothelioma.

Event_Moderator {question presented} What are mesothelioma's symptoms?

Dr_Sugarbaker Mesothelioma begins to develop on the surface of the lung and begins to secret a clear fluid. As it's building up on the chest, the lung begins to slowly collapse. So the primary symptom is a progressive shortness of breath with exercise or walking. So shortness of breath is usually the first symptom. As the tumor grows into the chest, the patients may experience pain in their chest.

Event_Moderator How well are doctors in this country acquainted with this disease? Will they know these symptoms?

Dr_Sugarbaker Well, because it is a relatively rare tumor, most physicians will see one or two cases over the course of several years. So, the experience that a physician needs to gain a certain insight into a tumor is almost impossible to get, which is why I think this particular tumor has been so difficult to understand, because any one group of physicians are not seeing a large number where they gain insights into how the disease acts and can then gain new strategies. It's also true that more recently, the rise of networks in health maintenance organizations has made it more difficult for patients to go from one health care network where there is no expertise in the disease, to a center where there is a large number of patients being seen and treated. What the HMO's many times tend to do is to keep patients in a fenced in network of physicians and hospitals.

Event_Moderator How is that going to affect a mesothelioma patient?

Dr_Sugarbaker If a mesothelioma patient, let's say in a particular town in Florida or some other state, is found to have mesothelioma and would like to go to NY or Boston or some other center where mesothelioma patients are treated on new protocols and the HMO requires an incredible expense, that tends to keep patients, unless they're independently wealthy, in their own network.

Event_Moderator What would one do in general upon diagnosis of mesothelioma?

Event_Moderator {question presented} What role does time play in fighting mesothelioma?

Dr_Sugarbaker Well, mesothelioma is one of the faster growing tumors. And so while a period of weeks will not make any substantial difference in terms of outcome in my experience, when you start talking a 3-6 month delay in therapy, you have much more difficulty in treating the disease. So, time is important.

Event_Moderator {question presented} What is the prognosis for mesothelioma?

Dr_Sugarbaker The prognosis is dependent upon a number of factors. They are: number one, what type of mesothelioma does the patient have? There are three types: the first is an epithelial type, the next is sarcomatous, and the last is a mixed type. Survival is more favorable in the first (epithelial) than the other two.

Event_Moderator What are the differences between these types?

Dr_Sugarbaker The sarcomatous and mixed types seem to act very much the same. And they are a more aggressive, faster growing tumor than the epithelial, and so our treatments are more effective against the epithelial subtype -- well, no one knows for sure, but, it is thought that the cell of origin (the first cell to become cancerous) is different in these types, so the original cell in epithelial is different than the original cell in the sarcomatous or mixed type. No one quite knows why that is.

Event_Moderator And as for the prognosis?

Dr_Sugarbaker More aggressive and the prognosis then depends on the stage of the disease and there are four stages. The first and best prognosis is when the tumor is confined to the lining of the lung and has not gone to any lymph nodes. That's stage 1. And, if appropriately removed and treated, roughly 50% of patients will live 5 years. Stage 2 patients are those who now have lymph node involvement, and depending upon the extent of lymph node involvement, their survival may range more in the 2-4 year length. Those first two stages are often treated with surgery because of the more limited amount of disease. Stage 3 patients are those where the tumor has gone into the abdomen or into the heart or into the opposite chest where surgery is not possible. Survival in this group is less than 6 months on average. Stage 4 patients are those where the tumor has gotten into the bloodstream. This is relatively rare for this type of tumor, but when it occurs, survival is usually relatively short.

Event_Moderator {question presented} What type of surgery is used in treating mesothelioma?

Dr_Sugarbaker For stage 1 and 2, there are several surgeries performed. The least invasive is to simply drain the fluid out and put a talcum powder or other agent which causes the lung to scar against the chest wall. But this approach is not in any way an attempt to remove any of the tumor. And, so it is what we call a 'palliative approach'. The second type is to actually open the chest and remove all the tumor from the surface of the lung. This is a 'plurectomy'. In the majority of patients, this is also a palliative approach.

Event_Moderator What does palliative mean?

Dr_Sugarbaker It means it is a procedure done to relieve symptoms from the time of surgery done to the time of death, not an attempt to cure the patient. In other words here we would try to prevent fluid from coming back but make no attempt to eradicate all the tumor. It's therapy ... making the life that you have remaining more functional, of better quality.

Event_Moderator What is the effect of the lung scarring?

Dr_Sugarbaker The effect of that is simply to 'glue' if you will, the lung against the chest wall, so that when the tumor secretes fluid, the lung cannot collapse. The third type of surgery is an extrapleural pneumonectomy. This operation has the best record for removing the maximal number of tumor cells. This is then followed either immediately or in a matter of weeks by chemotherapy which then attempts to eradicate even more of the remaining cells, and this is finally followed by radiation treatment to the chest and this completes the so-called 'tri-modality therapy' that our group and others have been using ... in other words surgery, chemotherapy, and radiation.

Event_Moderator What is the success rate of chemotherapy and radiation for this kind of cancer?

Dr_Sugarbaker Well, chemotherapy and radiation therapy alone have not been shown to effect survival beyond supportive care only. But in combination with an operation which removes 99.9% of the tumor cells, there is good evidence that significant life extension can result.

Event_Moderator What is involved in the extrapleural pneumonectomy?

Dr_Sugarbaker The patient undergoes a series of tests before surgery is contemplated to determine whether the patient can, indeed, stand the surgery successfully and safely. Following this series of tests of the heart, lung function in the remaining lung, and following X-rays to determine whether the tumor is still stage 1 or 2, then the patient is considered a candidate for this procedure. This requires removal of the lung of the diaphragm (the muscle between the lung and the abdominal contents) as well as the covering on the heart. This is followed by reconstruction of the diaphragm and heart covering with plastic.

Event_Moderator What is the benefit of using plastic?

Dr_Sugarbaker It is impermeable, so fluid from the abdomen or chest is kept separate from each other. Also it is inert, meaning it does not cause a tissue reaction. It's very tough (gortex).

Event_Moderator {question presented} You pioneered the Brigham Staging System. Could you tell us about the system, and its role in fighting mesothelioma?

Dr_Sugarbaker Well, the Brigham Staging System is a system which I described to you a few moments ago, which has allowed us to determine which patients may benefit most from surgery. The problem in mesothelioma has been that because all patients without therapy are dying within a year or so. It has been hard to understand what features of the tumor in a particular patient may signal that this patient would benefit from aggressive treatment. So, we began our tri-modality therapy and for the first time, were able to stratify survival, that is to say some patients living a very long time compared to conventional treatment. Once we had some long-term survivors, we could determine what features of those patients would predict in an untreated patient someone who would benefit from this treatment. And, that is how the staging system was born. So, because we had some long-term survivors, we could determine things like cell type, extent of disease, involvement of lymph nodes, and other what we call 'prognostic variables'. We could then group the variables together to determine which patients before treatment would benefit, and those are the stage 1 and stage 2 patients.

Event_Moderator How long is long-term?

Dr_Sugarbaker Years. Five, six, seven years .... 10 years. Now, the other information that we gained was that we followed and cared for a number of patients who, following treatment, did have the disease return. So, we looked at the patterns of failure. That is to say, what is the pattern of the way the disease comes back? And, what we found was that the majority of patients' tumor, when it returned or 'recurred' did so at the time in the abdomen, and roughly 1/3rd of the time in the same chest where we had removed it. So, the majority of patients' disease seems to come back locally when it comes back. This is different than other types of cancer where the blood carries cells to different parts of the body ... brain, liver, bones and so forth.

Event_Moderator Why is that?

Dr_Sugarbaker Well, we don't quite know why this disease tends to come back only locally. We are studying it here, my colleague Dr. Raphael Bueno is studying the genetic make up of these tumors... trying to determine why they behave the way that they do. But, nevertheless, understanding this behavior of the tumor at the time of recurrence was only possible because we had long-term survivors. So, this understanding has allowed us to develop new strategies that are aimed at smothering, killing the tumor cells locally, even beyond our surgical removal.

Event_Moderator What strategies would those be

Dr_Sugarbaker Well, we currently have a protocol which we began in September of '98, which seeks to capitalize on this new understanding of the disease pattern of failure. We are performing the extrapleural pneumonectomy and then at the time of surgery, after the removal of the lung, we are bathing the abdomen and the chest with heated high dose chemotherapy. So, we are driving the concentration of chemotherapy to very high levels within a millimeter or two of the surface of the chest and abdominal cavities. And, to protect the body, meaning the other organs, we are giving a drug that inactivates the chemotherapy. So, any chemotherapy that is absorbed is inactivated. But, we get very high concentrations of chemotherapy at elevated temperatures where we want it, which is locally in the abdomen and the chest. It's called 'phiosulfate." That is infused into a vein, goes into circulation once, and then comes out through urination .... so it is constantly clearing the chemotherapy through the system. Now the heat is given because we know that if you heat cells, their rate of activity goes up ... particularly cancer cells. The idea is to heat the cancer cells up, get them excited so that they suck up the poison, namely the chemotherapy.

Event_Moderator How do you keep the chemotherapy effective within the chest cavity?

Dr_Sugarbaker It's a circuit that pumps the chemo from the top of the chest cavity, where it then flows through the open diaphragm to the drainage catheter which is placed in the pelvis. There it is sucked out by a pump, put through a heater, and pumped back to the top of the chest, so it's a constant flow and it's done for one hour. The studies show that after about 40 minutes, no additional cells are killed, and we do it once because we don't have the opportunity to heat this again without a patient being asleep it would be painful. We try to take advantage of the fact that the patient is under anesthesia to give treatments like this that would otherwise be impossible but may be more effective.

Event_Moderator How new is this treatment?

Dr_Sugarbaker We devised this therapy and we built on our experience with doing the operation safely and quickly and with our understanding of the pattern of failure to devise this new approach.

Event_Moderator What has the outcome been?

Event_Moderator {question presented} Could you tell us about any promising drugs on the horizon for mesothelioma?

Dr_Sugarbaker There are a number of drugs that have been around for a fairly long time, but in new combinations appear to be more effective than we would have predicted. Gemcytobean, when combined with Cisplatinin has been more effective with, in some studies, almost 40% of patients showing some response. But still, the majority of patients' tumors show no response to these drugs. Gene therapy has been looked at by a variety of centers, but no clinical success has been produced by this approach. Combining surgery with photodynamic therapy has shown some promise. And Dr. Joe Friedberg, of the University of Pennsylvania has done some interesting work here. The idea being that the photodynamic light will kill the remaining tumor cells based much on a similar strategy of ours, but instead of chemo, he's using photodynamic treatment.

Event_Moderator {question presented} What about this disease in particular made you want to become a specialist in the area?

Dr_Sugarbaker Well, I trained in thoracic surgery at the University of Toronto after finishing surgery here at Harvard and I came back to the Brigham as Chief of Thoracic Surgery in 1988. Among my very first patients referred to me in practice were two veterans from the Quincy, Mass. shipyards, as well as Charlestown Navy Yard and the Maine shipyards. So, I began to see a unique number of patients in my practice based on where I was located. And it appeared, when I inquired to colleagues around the country, that no one had any allusions to this particular tumor, so it became an area of deep interest to me to try to use the place where I had been placed in practice in seeing this number of patients, gaining insight and experience in trying to come up with something which would help these people. I had been trained in the appropriate specialty, thoracic surgery, and I had come back to where people had been referring patients to me and I happened to be in a part of the country where there was a relatively large number of cases, and so we set to work. I would say to patients and families of patients with mesothelioma that it is not hopeless in every case.

Event_Moderator Thank you for joining us, Dr. Sugarbaker. Please join us again today at 7:00 p.m. EST in the World Watch and Health News Auditorium where we will discuss "Lupus: A Body Against Itself," with Janis Pluss, MSW.

Dr_Sugarbaker You're very welcome. Thank you very much. I really enjoyed this.

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