The University Medical Center Essen – Ruhrlandklinik is a leading center for respiratory diseases in western Germany. It combines outstanding medical expertise with close collaboration between the Ruhrlandklinik team and various other specialists, as well as centers of excellence at the University Medical Center Essen. This unique alliance enables comprehensive surgical, interventional, and pharmacological treatment of all respiratory diseases at the highest level.
The Department of Thoracic Surgery and Thoracic Endoscopy at the Ruhrlandklinik holds a prominent position and ranks not only among the most significant but also among the largest facilities of its kind in all of Germany. With an impressive number of over 2,000 procedures performed annually, it demonstrates its expertise and influence. Prof. Dr. Servet Bölükbas, Director of the Department of Thoracic Surgery and Thoracic Endoscopy and Head of the Mesothelioma Unit at Essen University Hospital – Ruhrlandklinik, and his team are at the forefront, performing these procedures with the utmost precision and expertise. In addition, approximately 4,000 outpatient consultations take place each year, reflecting the clinic’s broad spectrum of expertise.
As a specialist in thoracic surgery, lung cancer, pleural mesothelioma, lung metastases, and mediastinal tumors, Prof. Dr. Servet Bölükbas possesses the world’s highest level of surgical expertise in pleural mesothelioma and is a co-author of the European Guidelines for Pleural Mesothelioma. For this reason, the editorial team of the Leading Medicine Guide took the opportunity to speak with him about this type of cancer, as it presents a number of challenges.
Pleural mesothelioma is a form of cancer that develops in the pleura, a thin layer of tissue that surrounds the lungs and extends over the chest wall, the diaphragm, and the mediastinal space. Identifying this disease is challenging due to its often nonspecific symptoms, as it can easily be confused with other lung conditions.
Various diagnostic methods are available to identify and diagnose pleural mesothelioma.
“First, there are imaging techniques such as chest X-rays, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). These can reveal signs of a tumor, such as thickening of the pleura or fluid accumulation in the pleural cavity (pleural effusion). However, it is important to note that while these procedures can detect abnormalities, they cannot definitively confirm whether the condition is mesothelioma or another disease. This is where tissue samples obtained through biopsies come into play. A biopsy is currently the gold standard for diagnosing pleural mesothelioma. This procedure involves removing a small tissue sample from the pleura for microscopic examination and molecular genetic testing. Thoracoscopy is crucial in this process; it involves making a small incision in the chest wall to insert an endoscope into the chest cavity and remove a sample. At the same time, this procedure allows for the removal of any accumulated fluid and an assessment of the extent of the disease. The tissue sample obtained during the biopsy is then examined under a microscope by a pathologist. “The pathologist looks for specific cellular features that may indicate mesothelioma. In addition, immunohistochemical tests can help distinguish mesothelioma cells from other similar cancer cells,” explains Prof. Dr. Bölükbas, outlining the various diagnostic options.
Symptoms of pleural mesothelioma can include shortness of breath, chest pain, a persistent cough, weight loss, and general weakness. Since these symptoms can also occur with other conditions, diagnosis can often be challenging.
In summary, the diagnosis of pleural mesothelioma requires a combination of imaging techniques and biopsies. Although imaging techniques can provide valuable information about the condition of the pleura, they are often not sufficient on their own to establish a definitive diagnosis. Tissue samples obtained through biopsies are crucial for the final diagnosis, as they allow for the identification of the exact type of tumor and the establishment of a precise diagnosis. Given the rarity of this disease, it is advisable to have these procedures performed, ideally, at a center specializing in mesothelioma.
Pleural mesothelioma is a serious and often difficult-to-diagnose disease, mainly because its symptoms frequently resemble those of other lung diseases or are general and nonspecific.
Professor Dr. Bölükbas lists the most common symptoms:
- Shortness of breath: This is often the first and most noticeable symptom. It is frequently caused by fluid buildup in the pleural cavity (pleural effusion), which takes up the space the lung needs to expand. The effusion compresses the lung.
- Chest pain: Patients often report a dull, persistent pain on the affected side of the chest. This can be caused by the tumor itself or by the pleural effusion.
- Cough: A persistent, dry cough may also occur.
- Weight loss and loss of appetite: As with many other types of cancer, unexplained weight loss can be a symptom of mesothelioma.
- Fatigue and weakness: These symptoms are common in many types of cancer, including pleural mesothelioma.
- Fever and night sweats: These may also occur in some patients.
“These symptoms can also occur with other lung diseases, such as pneumonia, tuberculosis, or other types of lung cancer, which makes diagnosis difficult. However, pleural mesothelioma is distinct in that it is typically associated with exposure to asbestos. A doctor will therefore take the patient’s medical history and occupational background into account to determine the likelihood of asbestos exposure. This can help distinguish mesothelioma from other possible diagnoses,” explains the thoracic specialist.
“It is very important to keep in mind that the symptoms of mesothelioma often do not appear until the advanced stages of the disease, at a time when the disease may already be quite advanced,” emphasizes Prof. Dr. Bölükbas. Therefore, early diagnosis plays a crucial role in enabling more effective treatment. Individuals who have been exposed to asbestos over a long period and develop symptoms should seek medical advice immediately to determine the best course of action.
Unfortunately, pleural mesothelioma is often not diagnosed until later stages.
“This is partly due to the disease’s long latency period—several decades can pass between exposure to asbestos, the primary cause of mesothelioma, and the onset of symptoms. Furthermore, the symptoms are often nonspecific and can easily be confused with those of other, less serious respiratory conditions. For these reasons, pleural mesothelioma is often not diagnosed until it is already advanced. The stage of pleural mesothelioma at the time of diagnosis has a significant impact on the prognosis and treatment options. In general, as with any other cancer, the earlier the stage, the better the prognosis and the more treatment options are available.
In the early stages, potentially curative treatments such as surgery as part of bi- or trimodal treatment regimens may be considered. During surgery, a complete pleurectomy (removal of the pleura) is performed. If adjacent structures (lungs, pericardium, diaphragm) are affected, localized resections and, if necessary, reconstructions may also be performed. These surgeries are often combined with chemotherapy/immunotherapy and/or radiation therapy to kill any remaining cancer cells. These types of surgeries require a great deal of expertise and experience. Therefore, these types of surgeries should be performed at designated mesothelioma centers of the German Cancer Society. The University Medical Center Essen-Ruhrlandklinik is the first certified facility in Germany for this purpose. The thoracic surgery team has extensive surgical experience with this rare tumor disease.
In later stages, surgery is often no longer an option. In these cases, systemic therapies such as chemotherapy, immunotherapy, or targeted therapies can be used to control tumor growth, alleviate symptoms, and improve quality of life,” says Prof. Dr. Bölükbas, describing the significant challenges of diagnosis.
Various factors influence the decision to choose a specific treatment option.
The treatment of pleural mesothelioma can involve a variety of approaches, including surgery, radiation therapy, chemotherapy, and, occasionally, more modern treatment methods such as immunotherapy or targeted therapy. The decision regarding the appropriate treatment depends on a number of factors.
Professor Dr. Bölükbas explains various treatment options:
- Stage of the disease: In the early stages, surgery may be offered to remove the tumor. In more advanced stages, where the cancer may have spread to other parts of the body, systemic therapies such as chemotherapy, immunotherapy, or targeted therapy are often more appropriate.
- Patient’s overall condition: The patient’s physical fitness and general health can influence treatment options. For example, surgery requires a certain level of physical fitness.
- Biological characteristics of the tumor: The exact type of mesothelioma (epithelial, sarcomatous, or mixed) and the results of genetic testing can influence treatment options. Some newer therapies target specific genetic alterations that may occur in certain types of mesothelioma.
- Patient preferences: Ultimately, the patient’s wishes and preferences are crucial. Treatment for mesothelioma can cause side effects and significantly impair quality of life, so it is important that the patient be involved in the decision-making process.
There have been advances in the treatment of pleural mesothelioma!
As our conversation continues, Professor Dr. Bölükbas offers affected patients a great deal of hope, as modern treatment options can be very successful in treating pleural mesothelioma.
Prof. Dr. Bölükbas mentions the following options:
- Immunotherapy: This approach harnesses the body’s own immune system to fight cancer. There are various types of immunotherapies, including checkpoint inhibitors, which release the immune system’s natural brakes, thereby enabling it to attack cancer cells more effectively. Drugs such as pembrolizumab and nivolumab have shown promising results in some studies.
- Targeted therapy: These therapies target specific genetic alterations or proteins that promote tumor growth. One example is the inhibition of the protein mesothelin, which is overexpressed in many cases of mesothelioma.
- Tumor Treating Fields (TTF): This is a relatively new treatment that uses electric fields to treat mesothelioma. A device worn outside the body generates an electric field that can disrupt the growth of cancer cells. In a clinical trial, TTF combined with chemotherapy showed improved survival in patients with pleural mesothelioma.
- Gene Therapy and Virotherapy: These experimental therapies aim to alter the genetic material of cancer cells or use viruses to attack cancer cells. Although they are still in the early stages of research, they could lead to new treatment options in the future.
It is important to understand that, although these therapeutic approaches are promising, they may not be equally suitable or effective for every patient. The success of a treatment can depend on various factors, including, among others, the individual characteristics of the tumor and the patient’s overall health. As a result, it is crucial for patients to discuss all available treatment options with doctors who specialize in treating mesothelioma and to carefully weigh the potential benefits and risks of these options.
There are a number of supportive measures and therapies available to patients with pleural mesothelioma to alleviate symptoms and improve quality of life. These are known as palliative or supportive therapies and are an important part of the overall treatment strategy.
Prof. Dr. Bölükbas explains the various therapies:
- Pleurodesis: In many patients with pleural mesothelioma, fluid accumulates in the pleural cavity, leading to breathing difficulties. A minor procedure is performed to drain the effusion. In some cases, pleurodesis can be performed, in which a substance is injected into the pleural cavity to cause the lung surface and the inner wall of the chest wall to adhere to one another, thereby preventing the recurrence of a pleural effusion. Another method is the insertion of a thin indwelling drain, through which the effusion can be regularly drained, especially when pleurodesis is not likely to be successful.
- Pain Management: Pain is a common problem among patients with pleural mesothelioma. There are a variety of medications and techniques available for pain relief, including non-opioid pain relievers, opioids, nerve blocks, and even certain types of radiation therapy. A good pain management plan can significantly improve quality of life.
- Respiratory therapy: Physical therapy, breathing exercises, and other types of respiratory therapy can help improve respiratory function and alleviate breathing difficulties.
- Nutritional Counseling: Many patients with pleural mesothelioma have problems with appetite or food intake. Nutritional counseling can help develop a meal plan that meets the patient’s nutritional needs and helps prevent weight loss and weakness.
- Psychosocial support: A cancer diagnosis can be emotionally very stressful, both for the patient and for their loved ones. Psychological counseling, support groups, and other forms of psychosocial support can play an important role in helping patients cope with their diagnosis and treatment.
- Palliative Care Teams: These teams, consisting of doctors, nurses, and other healthcare professionals, specialize in relieving symptoms and improving quality of life for patients with serious illnesses such as mesothelioma. They can assist with pain management, symptom relief, and emotional support.
It is crucial to understand that palliative care should by no means be viewed as a refusal of treatment.
Instead, it is an essential complement to cancer treatment, aimed at alleviating symptoms and improving quality of life, regardless of the stage of the disease. The diagnosis and treatment of pleural mesothelioma is a complex task that requires specialized expertise and extensive experience. Imaging tests and biopsies play a crucial role in diagnosis, while various treatment options—including surgery, chemotherapy, radiation therapy, and newer immunotherapy and targeted therapy approaches—may be considered depending on the individual patient’s situation and the stage of the disease.
“It is also important to emphasize that pleural mesothelioma is often diagnosed at a late stage, which can affect both the prognosis and treatment options. Therefore, early diagnosis is crucial for individuals who have had long-term exposure to asbestos and develop symptoms. In addition, palliative or supportive therapies are an essential component of the treatment strategy for pleural mesothelioma, aimed at alleviating symptoms and improving quality of life. These include pain management, respiratory therapy, nutritional counseling, and psychosocial support. Finally, it is important to emphasize that the treatment of pleural mesothelioma should take place at specialized centers such as the University Medical Center Essen-Ruhrlandklinik, which is part of the West German Tumor Center and the National Cancer Center (NCT) West, to ensure optimal diagnosis and treatment,” explains Prof. Dr. Bölükbas, bringing our conversation to a close.
Professor Dr. Bölükbas, thank you very much for these informative insights into the great challenges involved in treating pleural mesothelioma!
