Mistletoe preparation (Viscum Fraxini-2) as palliative treatment for malignant pleural effusion: a feasibility study with comparison to bleomycin.

BACKGROUND: Malignant pleural effusion is a common problem in patients with solid tumours. It has a significant impact on quality of life, and, hence, there is a substantial need to investigate new agents to treat it. PATIENTS AND METHODS: This is a prospective randomised controlled study, including patients with symptomatic recurrent malignant pleural effusion of different primaries. Patients were randomised into two groups: the first group received five ampoules of mistletoe preparation with defined lectin content (Viscum Fraxini-2, ATOS Pharma) diluted in 10 cc glucose 5% solution. Re-instillation was repeated every week until complete dryness of the pleural fluid was achieved (the maximum duration of the therapy was eight weeks). The second group received 60 units of bleomycin once intrapleurally. AIMS: The primary aim of this paper was to evaluate the efficacy of mistletoe preparation as a palliative treatment for malignant pleural effusions in comparison with bleomycin. The secondary aim was to evaluate the tolerability of the mistletoe preparation. RESULTS: A total of 23 patients were included and followed up during the study from December 2007 to January 2012: 13 patients received mistletoe preparation, and ten patients received bleomycin. Overall clinical response was reported in 61.5% of the mistletoe preparation arm versus 30% in bleomycin arm (p = 0.2138), 95% CI = (-0.1203, 0.6325). The toxicity of both arms was mild and manageable; the mistletoe preparation arm included fever, chills, headache, malaise, and, in two cases, allergic reaction, which was controlled by discontinuation of the drug and steroid injection. CONCLUSION: Mistletoe preparation is an efficient and well tolerated sclerosant agent which needs further investigation.

Analysis of the effect of radiotherapy on malignant pleural mesothelioma when given on adjuvant or palliative basis.

BACKGROUND AND OBJECTIVE: This retrospective study was designed to evaluate the response and survival of malignant pleural mesothelioma to radiotherapy when delivered with surgery and chemotherapy and when delivered alone or with chemotherapy. METHODS: A study for 110 patients with malignant pleural mesothelioma who presented to radiotherapy department, National Cancer Institute, Cairo and received radiation therapy in the period fromJanuary 1999 to July 2007. RESULTS: Forty-six patients (41.8%) received trimodality therapy (surgery & adjuvant or neoadjuvant chemotherapy & adjuvant radiotherapy), while bimodality therapy (chemotherapy & radiotherapy) in 38 patients (34.5%), while 26 patients (23.6%) received single modality therapy (palliative radiotherapy), 22 patients (20%) developed local recurrence, 22 patients (20%) developed distant metastases months, 14 patients (12.7%) developed local disease progression, 25 patients (22.7%) are still alive and free of disease at time of reporting. The median survival for all patients was 16 months, while 12 and 18 months overall survival were 63.6% & 31.8% respectively while median survival for stage II, III, IV patients was 16.5, 12.5 and 8 months respectively. CONCLUSION: Multimodality approach involving surgery, chemotherapy and radiotherapy have been evaluated and proved its superiority in improving survival, especially in stages II.

Prevalence and pattern of lymph node metastasis in malignant pleural mesothelioma.

BACKGROUND: The incidence and pattern of nodal metastases in mesothelioma are not well understood. This study was conducted to evaluate the prevalence and pattern of nodal metastasis in mesothelioma patients. METHODS: The study included 53 patients with mesothelioma. The first 37 patients (group I) underwent combined modality treatment without preoperative mediastinoscopy. The second group included 16 patients (group II) with pretreatment mediastinoscopy. RESULTS: A total of 18 patients had positive lymph nodes, 12 in group I and 6 in group II; of the latter, 4 had positive mediastinoscopy and 2 had positive nodes on final pathology. Postoperatively, a mean of 14 nodes were dissected (range, 5 to 34). In the post-pleuropneumonectomy group, 6 of 14 patients had positive hilar node metastases in addition to positive mediastinal lymph nodes. One patient had positive hilar nodes only. Of the 49 patients operated on, only 7 had no lung invasion by pathologic evaluation, and none had positive hilar nodes. The mechanism of spread of the disease to hilar nodes may be through lung invasion and not due to direct spread from the pleura. This observation raises the possibility that mediastinal nodes should be considered the primary station in patients with mesothelioma, whereas hilar node metastasis necessitated lung invasion first. CONCLUSIONS: The pattern of nodal metastases may be different from that of lung cancer, and multicenter studies are needed to evaluate this observation.