Lung Cancer Update, Issue 3, 2016 (Video Program) - Video 25Case discussion: A 55-year-old man with recurrent epithelioid mesothelioma
3:40 minutes.
TRANSCRIPTION:
DR BLUMENSCHEIN: So this is actually a gentleman who presented at another institution before I saw him originally in 2011, and at that time he underwent a resection. He had an epithelioid mesothelioma. And there are 3 variants: there’s epithelioid mixed, which is a combination of sarcomatoid and epithelioid, and then sarcomatoid. And epithelioid’s the best actor of the group and tends to be more sensitive to chemotherapy. And when you’re considering an intervention, such as a decortication or an extrapleural pneumonectomy, if you have an epithelioid tumor, that’s an indication to consider that if the patient meets the other staging criteria. But if they have sarcomatoid, either as part of the mixed histology or sarcomatoid at all, then you don’t proceed to surgery. DR LOVE: You mentioned the question of decortication. What are the types of surgical procedures that are done? And how do you decide whether or not to embark on these? DR BLUMENSCHEIN: So there are several variations on the theme. There’s extrapleural pneumonectomy, which is the most aggressive, which is essentially a pneumonectomy as well as removal of the pleura. And then there’s decortication, which is not as involved as an extrapleural pneumonectomy. I think what drives this is (A) the patient has to meet the staging criteria, have operable disease and have a functional status, which will allow him to proceed with surgery and have a meaningful quality of life after surgery, in addition to which I think it comes down to a skill set. Some physicians are more adept with extrapleural pneumonectomy than others. I think the tertiary centers have a lot of experience with this. And this is an area which is in evolution about what the best approach is surgically. For this particular patient, and when he first presented in 2011, he underwent decortication and then he underwent talc pleurodesis. And, unfortunately, he recurred. And at that point he was treated with pemetrexed and carboplatin, which he completed in June of 2012. And this was then followed by a redo thoracotomy and decortication with a little more extensive resection of his diaphragm and reconstruction in April of 2012. Did well. And then in 2015, he developed recurrent disease. And then he came to MD Anderson, where I saw him for the first time. He wasn’t a surgical candidate at that point. And we knew he had responded to his pemetrexed/carboplatin several years prior, so we proceeded to treat him with pemetrexed and cisplatin, with or without the addition of cediranib, which is an oral VEGF tyrosine kinase inhibitor, as part of a clinical trial that we’re running. So he completed 6 cycles of the combination chemotherapy and had a response and continued on with the pill, which is either placebo or cediranib and is now in the maintenance phase of this where he’s taking the placebo/cediranib and following up about every 2 months. DR LOVE: How is he doing in terms of side effects and tolerability? Do you think he’s on the placebo, or it’s kind of hard to tell? DR BLUMENSCHEIN: It’s kind of hard to tell. He actually tolerated his chemotherapy quite well. And got all 6 cycles in, as I mentioned. Responded. Didn’t develop neuropathy. Didn’t develop tinnitus. And continued to work. He’s now taking the placebo/cediranib and is tolerating things well. DR LOVE: And cediranib, as you mentioned, is an antiangiogenic. Do you see hypertension and other — DR BLUMENSCHEIN: Right. So some of the things you would see with this as a class effect, hypertension. Certainly you monitor that. You look for proteinuria. |