Should Surgery Be Performed for Sarcomatoid Mesothelioma?

Sarcomatoid mesothelioma is widely recognized as the most aggressive and rare form of mesothelioma. Because of how quickly it spreads and how poorly it responds to treatment, surgery is often not considered a helpful option for most patients.

Still, recent research suggests that there may be limited situations where surgery could play a role. The decision is complex and depends heavily on the patient’s overall health, disease stage, and treatment plan.

Difficulty Treating Sarcomatoid Mesothelioma

Mesothelioma develops in the lining of the lungs and is most often linked to asbestos exposure. It is generally divided into three main types: epithelioid, biphasic, and sarcomatoid.

Among these, sarcomatoid mesothelioma is the least common and the most aggressive. It tends to spread quickly through the chest and surrounding tissues and is often resistant to standard treatments like chemotherapy and radiation.

Because of this behavior, patients with sarcomatoid mesothelioma typically have a shorter life expectancy than those with other cell types. In many cases, survival is measured in months rather than years.

Why is Surgery Not Recommended for Treatment of Sarcomatoid Mesothelioma

Surgery for mesothelioma is designed to remove as much visible tumor as possible. However, sarcomatoid mesothelioma often grows in a diffuse pattern, making complete removal extremely difficult.

Research has shown that surgical treatment does not consistently improve survival for patients with sarcomatoid disease. In fact, outcomes for surgery in this subtype are generally poor compared to other forms of mesothelioma.

For this reason, many clinical guidelines advise against surgery for sarcomatoid mesothelioma, especially when the disease is advanced or has spread widely.

What Recent Research Suggests

Although surgery is not typically recommended, newer studies have explored whether carefully selected patients might benefit from an aggressive, multi-step treatment approach.

One recent clinical study by Dr. Raphael Bueno and his team at Brigham and Women’s Hospital examined outcomes of patients with sarcomatoid mesothelioma who underwent a lung-sparing surgical procedure known as pleurectomy / decortication, where the lining of the lung and visible tumor are removed while the lung itself is preserved.

The study found that:

Surgery is not standard, but may feasible in selected cases, on carefully selected individuals and only at specialized centers.
Multimodal therapy is key and other modalities of treatment must be used. The study was conducted prior to the approval of immunotherapy for mesothelioma, so it doesn’t take into account benefits achieved through systemic immunotherapy treatments which could further help improve outcomes in sarcomatoid mesothelioma.

The Role of Multimodal Treatment

Today, doctors are more likely to consider a combination approach rather than surgery alone. This is often referred to as multimodal therapy.

Multimodal treatment may include:

Surgery in select cases
Chemotherapy before or after surgery
Emerging treatments such as immunotherapy
Supportive care to manage symptoms and maintain quality of life

Even in cases where surgery is considered, it is rarely used on its own. It is typically part of a broader treatment strategy aimed at controlling the disease rather than curing it.

Selection Criteria for Patients with the Sarcomatoid Subtype of Mesothelioma

One of the most important factors in determining whether surgery might be appropriate is patient selection.

Patients with better lung function and overall physical health tend to tolerate aggressive treatments more effectively. In some studies, individuals with strong pre-surgical lung capacity showed longer survival compared to those with weaker respiratory function.

Other factors doctors evaluate include:

Stage of the disease
Extent of tumor spread
Overall health and age
Ability to tolerate additional therapies

Even with these considerations, surgery remains controversial for sarcomatoid mesothelioma.

The Bottom Line

For most patients with sarcomatoid mesothelioma, surgery is not a standard or highly effective treatment option. The disease is usually too aggressive, and outcomes after surgery alone are generally limited.

However, in rare and carefully selected cases, surgery may be considered as part of a broader treatment plan that includes chemotherapy or other therapies.

Because every case is different, treatment decisions should always be made by a specialized mesothelioma care team with experience in managing this rare cancer type.

To discuss treatment options for your specific situation, including a potential surgical resection, contact our expert mesothelioma nurse.

Parp-Inhibitors show promise in mesothelioma treatment

At this year’s American Association for Cancer Research, investigators from the United Kingdom announced the positive results of a mesothelioma clinical trial testing a relatively new class of targeted drugs: the PARP inhibitors.

The study Niraparib Efficacy in Patients With Unresectable Mesothelioma (NERO) enrolled 88 patients randomized into two groups showed that those treated with niraparib extended the median progression-free survival by 1.5 months compared to the arm of patients who only received symptom management care.

Eligible patients had already undergone standard chemotherapy treatment for mesothelioma with success, but they relapsed with the cancer coming back or growing.

Currently, there are no proven therapies for mesothelioma beyond initial treatment and after recurrence. Data on the efficacy of chemotherapy are limited, and immunotherapy retreatment has been only a recent addition to the doctors’ treatment arsenal.

What are PARP inhibitors?

Simply put, PARP inhibitors are drugs that prevent the enzyme known as poly ADP ribose polymerase (PARP) from doing its job of repairing damaged DNA in cells. If not repaired, damaged cells, including cancer cells, die. Conversely, if repaired, even if the repair is erroneous, the cells go on to survive and replicate which can be problematic with cancerous cells. Typically, patients who responded to chemotherapy previously are more likely to see a benefit from this class of drugs. While this study did not require patients enrolled to have a somatic BAP1 deletion, other studies looking into this agent often do. Somatic mutations are those not passed down to offspring and are instead acquired in the cells over time. BAP1 is a tumor suppressor gene, therefore its deletion is understood as consequential in mesothelioma.

Clinical trials employing PARP inhibitors currently available in the United States

While this study took place in the United Kingdom, in the U.S. clinical studies utilizing PARP inhibitors have been available to mesothelioma patients who fit certain eligibility criteria. Currently, one of those studies is still open and enrolling.

Olaparib in Patients with HRD Malignant Mesothelioma is available at the University of Chicago Medicine to patients with the loss of BAP1 and/or a germline (passed down from parents) or somatic (acquired over lifetime) mutation that disrupts protein function in at least one of the patient’s genes.

Could there be another mesothelioma cell type beyond epithelioid, sarcomatoid, and biphasic?

In recent years, mesothelioma histology has become more important than ever, as researchers find that certain treatments are more effective against different cell types. The epitheliod subtype of mesothelioma is by far the most common and is considered the least aggressive of the three types. The sarcomatoid subtype is less common but most aggressive. When a tumor contains both types of cells, it is known as biphasic.

As far as treatment goes, epitheliod mesothelioma tends to respond to chemotherapy better than the sarcomatoid subtype, while benefits of immunotherapy are more pronounced in patients with the more aggressive sarcomatoid subtype.

But now, researchers believe to have identified mesothelioma cells that are neither sarcomatoid nor epitheliod. In the preprint article “Comprehensive multi-site profiling of the malignant pleural mesothelioma micro-environment identifies candidate molecular determinants of histopathologic type,” by Raphael Bueno, MD, et al., the authors suggest that a third category of cells exist in the tumor microenvironment of mesothelioma and are most prevalent in tumors of patients with biphasic disease. Those cells have been named “uncommitted” because the idea is that at some point they might take on an epitheliod or sarcomatoid appearance.

As the researchers examined tumor samples, they noticed that in predominantly epitheliod, and in predominantly sarcomatoid mesotheliomas, such uncommitted cells were few, but in biphasic mesothelioma they were substantial.

Significance of histology (tumor cell type) for mesothelioma patients

The cellular type of the mesothelioma tumor helps doctors determine the prognosis and best treatment for a patient. For example, it is currently known that survival varies depending on the cell type. Patients with epitheliod mesothelioma have the best prognosis, and those with sarcomatoid the worst. The biphasic patients tend to fall in between depending on the proportion of epitheliod vs sarcomatoid cells in their tumors. Moreover, tumor histology helps doctors identify the best treatment for a patient. Sarcomatoid and biphasic tumors have shown the greatest benefit when treated with immunotherapy, and the least benefit when treated with chemotherapy. As mesothelioma research continues to advance, the tumor microenvironment is seen as far more important than individual cells in the proliferation of this cancer.

Because mesothelioma prognosis currently relies so heavily on histology, this discovery adds another layer of nuance to an already complex disease. In addition to understanding the significance and purpose of these uncommitted cells, another question for researchers to untangle in the future will be to understand whether these uncommitted cells ultimately become committed, and whether they commit to the epitheliod or sarcomatoid type and why.

New episode of Meet the Mesothelioma Experts About Financial Compensation for Mesothelioma

Last week, the Mesothelioma Applied Research Foundation released a new episode of its Meet the Mesothelioma Experts: Legal Edition series discussing financial compensation issues for mesothelioma patients. Featured guest of the program was Joseph Belluck, partner with the Belluck Law firm, who was interviewed by the organization’s board of directors’ member, Cheryl Bruner. Mr. Belluck answered a number of questions of interest to those who have just had a mesothelioma diagnosis and their families.

Acting with Urgency

One of the take-home messages is that while a mesothelioma diagnosis requires medical urgency and treatment, so does the legal process. This is due to a number of issues, the statute of limitations being one, but not the only one. As Mr. Belluck states in this program, it is important to file a lawsuit as soon as realistically possible in order to get a place in line, even if later adjustments are necessary. An experienced law firm will know enough information about a case very quickly and will be able to proceed with expedience.

“Usually, right after contact, we file the case, we start working on the bankruptcy trust claims and also starting to work on the lawsuit, which we do in tandem. Typically, the first settlements will come in about 45 – 60 days and the whole case will be completed within 12 months,” said Mr. Belluck in the program.

Mr. Belluck adds that whether a patient chooses to hire his firm or another firm, he still encourages them to make sure to do so quickly for the reasons outlined above.

Watch the video:

00:00 Introduction
1:11 Why Belluck Law chooses to sponsor the Meso Foundation and how their mission resonates
6:15 How Belluck Law works within the meso community
7:47 Next steps in the legal process after diagnosis
11:05 Litigation timeline after choosing a law firm
14:01 How much time and effort is anticipated to dedicate to litigation
16:14 Options for taking legal action
21:58 Timeline of settlement funds
28:05 How much of a settlement does a patient/family receive
35:37 Advice for future clients in deciding legal action

Compensation Programs for Mesothelioma Patients and their Families

There are several main compensation programs that are typically available to mesothelioma patients. They include simple programs like health insurance, private disability insurance, social security disability benefits, and workers compensation if the person is still employed. Additionally, veterans’ benefits are available for people who served in the military and have a service connection to asbestos exposure. Mesothelioma bankruptcy trusts are another avenue to pursue for compensation. There are about 40-50 individual funds that have been set up by companies that made asbestos products and went into bankruptcy. As part of their bankruptcy reorganization, they set up a fund for their product. And the last option available is to file a lawsuit individually, not a class action, against the companies that made asbestos products that the patient was exposed to.

Mr. Belluck and his law firm offer free consultations by submitting a quick form on the firm’s website at www.belluckfox.com.

Mesothelioma Treatment News: Delivering therapies directly into the pleural space

In a new article published in the medical journal The Lancet (Leveraging the pleural space for anticancer therapies in pleural mesothelioma by Blythe at al., 2024), authors make an argument for renewed focus toward therapies that can be delivered directly into the intrapleural space.

The benefit of such therapies is that by targeting the tumor directly, doctors are able to use higher doses of medication for increased likelihood of success while limiting toxicity to the patient.

Pleural mesothelioma is a cancer of the lining that surrounds the lung, which is called the pleura. So far, most attention has been devoted toward finding systemic treatments that work – a feat that has proven to be quite challenging. Systemic treatments are treatments such as chemotherapy or immunotherapy, which are administered through a vein, that travel throughout the entire body to kill the cancer cells wherever they may be. These treatments are currently the standard of care, but many patients’ tumors still don’t respond to them well. Because most patients’ cancer is quite advanced at diagnosis, this approach is often the only option anyway.

However, some patients receive a very early diagnosis either incidentally, meaning they underwent a surgical procedure for a different issue when mesothelioma was found; or because they presented with fluid buildup in the pleural space (called a pleural effusion) that prompted further testing. Recent staging studies suggest that this population of patients is significantly larger than previously thought and might include anywhere between 15% to 40% of diagnoses. For such patients, benefits of systemic therapies are unclear because studies that led to the FDA approval of chemotherapy and immunotherapy predominantly included unresectable (non-surgical candidates) stage 3 and 4 patients. Typically, early-stage patients are either offered surgery, or watchful waiting. But in the past year, this approach has been further complicated by a somewhat controversial surgical study called MARS 2 which showed limited benefits of surgery in the management of mesothelioma. Therefore, the expectation is that the number of early-stage patients who receive no immediate treatment will increase.

For this reason, the authors suggest that development of studies to test the effectiveness of localized intrapleural treatment is important and feasible and can be performed during the wait period between diagnosis and standard treatment, called window of opportunity.

In its early stages, mesothelioma’s only symptom might be a pleural effusion, either symptomatic or not. If symptomatic, once the effusion is drained, the patient feels better. But as long as mesothelioma is present on the pleura, it is rare for the fluid to stop building up. Currently, there are two ways to manage this problem:

With a procedure called pleurodesis. The purpose of the procedure is to close the space in the pleura where fluid accumulates. This procedure makes the pleural space mostly inaccessible.
By inserting a drain catheter into the pleural space to drain the fluid as it builds up, thus leaving the pleural space accessible.

Critically, administering intrapleural therapy will require access to the pleura, so the initial course of action for palliation of the pleural fluid will need to be reviewed and will require consensus among providers. It is important to note that a previous pleurodesis might not necessarily be a disqualifying factor as long as pleural pockets of air/fluid are still present.

This article is a summary of a research study and does not constitute medical advice.

Category: Mesothelioma