Mesothelioma Surgeon Jacques Fontaine: Experienced Specialists Matter
There are good reasons why people say it is important to see an experienced specialist when it comes to pleural mesothelioma. Symptoms of mesothelioma often mimic other diseases that are less aggressive and very often benign. It’s why it can takes months, sometimes close to a year, to get a definitive mesothelioma diagnosis.
The most common first symptom you’ll see in many patients is a shortness of breath. You also might see weight loss, pain in the chest or tightness of the chest. And one of the first signs you see on an X-ray is a pleural effusion (fluid accumulation around the lung).
But just because you have fluid around the lungs does not mean you have mesothelioma. A lot of other diseases present with fluid around the lungs. The majority of patients with fluid around the lungs do not have mesothelioma.
Some of the same symptoms can be attributed to benign types of disease. You could have a benign inflammation of the pleura (lining around the lung) or an infection of the fluid around the lung after a pneumonia. Some patients after chest or heart surgery or a viral infection may also have fluid around the lung.
However, one must get concerned and a red light should go on if the fluid recurs and is associated with a thick rind or layer on the lung on CT Scan. This is especially true for patients who had a previous significant exposure to asbestos.
I will point out that I’ve had patients who say, “I was exposed to asbestos a month ago, and now I have fluid around my lung, do I have mesothelioma?”
The answer is no. It takes an average of 25 years between exposure and the development of mesothelioma.
So, if the red light goes on because the fluid keeps recurring, then we need to try and figure out what’s really going on because it’s probably more than an infection or inflammation.
How We Diagnose Someone for Mesothelioma
The first thing we do is remove the fluid with a little needle called a thoracentesis. We send the fluid for analysis. We’re looking for certain types of cells and certain types of protein in it. Often this is not diagnostic. If the fluid comes back negative, after the thoracentesis, that doesn’t mean for sure you don’t have mesothelioma. It just means it has not been diagnosed. If the suspicion still is high, then we need to go on to a more definitive, or advanced, testing.
We would do a thoracoscopy (also known as VATS) by inserting a small camera between the ribs and taking biopsies — actual little pieces of the tumor from the pleura (lining around the lung). The likelihood of a correct diagnosis with this technique is much higher, more than 95 percent accurate. Most often it would require general anesthesia and a one-day hospital stay.
The experience of the pathologist reviewing the biopsies is very important. Because it’s so difficult to tell on a microscopic level the difference between cancerous mesothelioma vs. inflamed mesothelial cells or other more common forms of lung cancer, it’s important that the biopsies get reviewed by a hospital or a medical center that has a pathologist who specializes in mesothelioma and examines a lot of samples.
At the H. Lee Moffitt Cancer Center, we deal with a very large volume of mesothelioma cases and have an entire team of specialists in this disease. It is common for biopsy samples from across the country to be sent to us for a second opinion.
Once we diagnose mesothelioma, we then have to figure out how far along the cancer has progressed. That is called staging. Staging is done with every type of cancer. Knowing the stage allows the physician to better predict the prognosis and the most appropriate treatment. Mesothelioma has a tendency to be a locally aggressive cancer, and rarely gives metastasize elsewhere.
A thoracoscopy (VATS) procedure not only can diagnose mesothelioma, but it helps stage the disease, tells us how advanced it is in the chest cavity. It also provides very important information, especially if considering surgery.
In addition to the thoracoscopy and a regular CT Scan to stage the cancer, we often do a PET scan. A PET scan is a specialized scan where a patient receives radioactive sugar through an IV.
Cancer cells will consume the radioactive sugar and light up bright on the scan. It helps us locate the areas of cancer cells. Although it’s very advanced technology, it’s not 100 percent precise. Sometimes particularly areas of inflammation or infection also will light up and mimic the cancer. So it’s not 100 percent accurate.
We sometimes also get an MRI of the chest, to look for possible invasion of the cancer into major nerves or major blood vessels of the chest. Invasion of these structures may preclude the patient from being a candidate for surgery.
Know the Type of Mesothelioma
There are three types of mesothelioma seen under the microscope: epithelial, sarcomatoid and biphasic (a mix of both epithelial and sarcomatoid). It is important to know what type it is because it will determine how aggressive the cancer is, and what the best treatment is.
If a patient gets told he/she has mesothelioma of the pleura, that’s not good enough. They must know if it is epithelial or sarcomatoid or if it is mixed. It makes all the difference in what you do next.
Sarcomatoid is the most aggressive type and usually there is no role for surgery, as surgery does not make patients live any longer. Epithelial is the least aggressive type, although a serious cancer nonetheless.
Dr. Jacques Fontaine is a thoracic surgeon and a major part of the Mesothelioma Program at the Moffitt Cancer Center in Tampa, Fla. He provides a doctor’s insight into this rare cancer and its treatment options.