Meningitis

Definition

Meningitis is an inflammation of the membranes (meninges) and cerebrospinal fluid surrounding your brain and spinal cord, usually due to the spread of an infection. The swelling associated with meningitis often triggers the “hallmark” symptoms of this condition, including headache, fever and a stiff neck.

Most cases of meningitis are caused by a viral infection, but bacterial and fungal infections also can lead to meningitis. Depending on the cause of the infection, meningitis can resolve on its own in a couple of weeks — or it can be a life-threatening emergency.

If you suspect that you or someone in your family has signs or symptoms of meningitis, seek medical care right away. Early treatment can prevent serious complications.

Symptoms

It’s easy to mistake the early signs and symptoms of meningitis for the flu (influenza). Meningitis symptoms may develop over a period of one or two days and typically include:

• A high fever
• Severe headache
• Vomiting or nausea with headache
• Confusion, or difficulty concentrating — in the very young, this may appear as inability to maintain eye contact
• Seizures
• Sleepiness or difficulty waking up
• Stiff neck
• Sensitivity to light
• Lack of interest in drinking and eating
• Skin rash in some cases, such as in viral or meningococcal meningitis

Earlier signs and symptoms that may suggest a serious infection, although not necessarily meningitis, include:

• Leg pain
• Ice-cold hands and feet
• Abnormally pale skin tone

Signs in newborns
Newborns and young infants may not have the classic signs and symptoms of headache and stiff neck. Instead, signs and symptoms of meningitis in this age group may include:

• Constant crying
• Excessive sleepiness or irritability
• Poor feeding
• A bulge in the soft spot on top of a baby’s head (fontanel)
• Stiffness in the baby’s body and neck

Infants with meningitis may be difficult to comfort, and may even cry harder when picked up.

If you or your child has bacterial meningitis, delaying treatment increases the risk of permanent brain damage. In addition, bacterial meningitis can prove fatal in a matter of days. Seek medical care right away if you or anyone in your family has any signs or symptoms.

When to see a doctor
If you or someone in your family has signs or symptoms of meningitis — such as fever, severe headache, confusion, vomiting and stiff neck — seek medical care right away. There’s no way to know what kind of meningitis you or your child has without seeing your doctor and undergoing testing.

Viral meningitis may improve without treatment in a few days, but bacterial meningitis is serious and can come on very quickly. If you or your child has bacterial meningitis, the sooner the treatment begins, the better the chances of a recovery without serious complications.

Also talk to your doctor if a family member or someone you work with has meningitis. You may need to take medications to prevent getting sick.

Causes

Meningitis usually results from a viral infection, but the cause may also be a bacterial infection. Less commonly, a fungal infection may cause meningitis. Because bacterial infections are the most damaging, identifying the source of the infection is an important part of developing a treatment plan.

Bacterial meningitis
Acute bacterial meningitis usually occurs when bacteria enter the bloodstream and migrate to the brain and spinal cord. But it can also occur when bacteria directly invade the meninges, as a result of an ear or sinus infection or a skull fracture.

A number of strains of bacteria can cause acute bacterial meningitis. The most common include:

• Streptococcus pneumoniae (pneumococcus). This bacterium is the most common cause of bacterial meningitis in infants and young children in the United States. It can also cause pneumonia and ear and sinus infections. When pneumococcal meningitis is associated with an ear infection, it’s not always clear which came first — the meningitis or the ear infection — because they usually occur together.
• Neisseria meningitidis (meningococcus). This bacterium is another leading cause of bacterial meningitis. Meningococcal meningitis commonly occurs when bacteria from an upper respiratory infection enter your bloodstream. This infection is highly contagious and may cause local epidemics in college dormitories and boarding schools and on military bases.
• Haemophilus influenzae (haemophilus). Before the 1990s, Haemophilus influenzae type b (Hib) bacterium was the leading cause of bacterial meningitis. But new Hib vaccines — available as part of the routine childhood immunization schedule in the United States — have greatly reduced the number of cases of this type of meningitis. When it occurs, it tends to follow an upper respiratory infection, ear infection (otitis media) or sinusitis.
• Listeria monocytogenes (listeria). These bacteria can be found almost anywhere — in soil, in dust and in foods that have become contaminated. Contaminated foods have included soft cheeses, hot dogs and luncheon meats. Many wild and domestic animals also carry the bacteria. Fortunately, most healthy people exposed to listeria don’t become ill, although pregnant women, newborns and older adults tend to be more susceptible. Listeria can cross the placental barrier, and infections in late pregnancy may cause a baby to be stillborn or die shortly after birth.

Viral meningitis
Viruses cause a greater number of cases of meningitis each year than do bacteria. Viral meningitis is usually mild and often clears on its own within two weeks. A group of common viruses known as enteroviruses are responsible for about 90 percent of viral meningitis in the United States.

The most common signs and symptoms of enteroviral infections are rash, sore throat, joint aches and headache. Many older children and adults with enteroviral meningitis describe the “worst headache I’ve ever had.” These viruses tend to circulate in late summer and early fall. Viruses associated with mumps, herpes infection, West Nile virus or other diseases also can cause viral meningitis.

Chronic meningitis
Ongoing (chronic) forms of meningitis occur when slow-growing organisms invade the membranes and fluid surrounding your brain. Although acute meningitis strikes suddenly, chronic meningitis develops over four weeks or more. Nevertheless, the signs and symptoms of chronic meningitis — headaches, fever, vomiting and mental cloudiness — are similar to those of acute meningitis. This type of meningitis is rare.

Fungal meningitis
Fungal meningitis is relatively uncommon. Cryptococcal meningitis is a fungal form of the disease that affects people with immune deficiencies, such as AIDS. It’s life-threatening if not treated with an antifungal medication.

Other meningitis causes
Meningitis can also result from noninfectious causes, such as drug allergies, some types of cancer and inflammatory diseases such as lupus.

Risk factors

Not completing the childhood vaccine schedule increases your risk of meningitis. So do a few other risk factors:

• Age. Most cases of viral meningitis occur in children younger than age 5. In the past, bacterial meningitis also usually affected young children. But since the mid-1980s, as a result of the protection offered by current childhood vaccines, the median age at which bacterial meningitis is diagnosed has shifted from 15 months to 25 years.
• Living in a community setting. College students living in dormitories, personnel on military bases, and children in boarding schools and child care facilities are at increased risk of meningococcal meningitis, probably because infectious diseases tend to spread quickly wherever large groups of people congregate.
• Pregnancy. If you’re pregnant, you’re at increased of contracting listeriosis — an infection caused by listeria bacteria, which may also cause meningitis. If you have listeriosis, your unborn baby is at risk, too.
• Working with animals. People who work with domestic animals, including dairy farmers and ranchers, have a higher risk of contracting listeria, which can lead to meningitis.
• Compromised immune system. Factors that may compromise your immune system — including AIDS, diabetes and use of immunosuppressant drugs — also make you more susceptible to meningitis. Removal of your spleen, an important part of your immune system, also may increase your risk.

Complications

The complications of meningitis can be severe. The longer you or your child has the disease without treatment, the greater the risk of seizures and of permanent neurological damage, including hearing loss, blindness, loss of speech, learning disabilities, behavior problems and brain damage, even paralysis.

Non-neurological complications may include kidney failure and adrenal gland failure. Your adrenal glands produce a number of important hormones including cortisol, which helps your body deal with stress.

Bacterial infections of your central nervous system progress quickly. Within a matter of days, the disease can lead to shock and death.

Preparing for your appointment

In some cases when you call to set up an appointment with your doctor, you may be told to go to the emergency room or call 911.

Depending on the cause, meningitis can be life-threatening. If you know you’ve been exposed to someone with meningitis and you have now developed symptoms, don’t wait to seek medical care. Go to an emergency room and let medical staff know immediately that you may have meningitis.

If your doctor determines that he or she should see you first, it’s critical to be well prepared for your appointment. Here’s some information to help you get ready, and what to expect from your doctor.

What you can do

• Be aware of any pre- or post-appointment restrictions. At the time you make the appointment, be sure to ask if there’s anything you need to do in advance, such as restrict your diet. Also ask if you may need to stay at your doctor’s office for observation following your tests.
• Write down any symptoms you’re experiencing, including changes in your mood, thinking or behavior. Make a note of when you first noticed each symptom on your list. Your doctor will want to know if you had cold or flu-like symptoms leading up to the symptoms you’re experiencing now.
• Write down key personal information, including any recent moves, vacations or interactions with animals. If you’re a college student, your doctor likely will ask questions about any similar signs or symptoms in your roommates and dorm-mates. Your doctor will also want to know your vaccination history.
• Make a list of all medications, as well as any vitamins or supplements, that you’re taking.
• Take a family member or friend along. Meningitis can be a medical emergency. Take someone who can soak up all the information your doctor provides and who can stay with you if you need immediate treatment.
• Write down questions to ask your doctor.

Prepare a list of questions so that you can make the most of your time with your doctor. For meningitis, some basic questions to ask your doctor include:

• What is likely causing my symptoms or condition?
• Other than the most likely cause, what are possible causes for my symptoms or condition?
• What kinds of tests do I need?
• What treatment do you recommend?
• Am I at risk of long-term complications?
• If my condition is not treatable with antibiotics, what steps can I take to help my body recover?
• Am I contagious? Do I need to be isolated?
• What is the risk to my family? Should they take preventive medication?
• Should I see a specialist? What will that cost, and will my insurance cover seeing a specialist?
• Do I need to take prescription medicine? If so, is there a generic alternative?
• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you’ve prepared to ask your doctor, don’t hesitate to ask questions during your appointment at any time that you don’t understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• When did you first begin experiencing symptoms?
• How severe are your symptoms? Do they seem to be getting worse?
• Does anything seem to improve your symptoms, or to make you even more uncomfortable?
• Do you know if you’ve been exposed to anyone with meningitis?
• Is anyone else who you live with having similar symptoms?
• What is your vaccination history?
• Have you been taking any immune-suppressant medications?
• Do you have any pre-existing health problems, including allergies to any medications?

What you can do in the meantime
When you call your doctor’s office for an appointment, describe the type and severity of your symptoms clearly. If your doctor determines that you don’t need to come in immediately, rest as much as possible while you’re waiting for your appointment. Drink plenty of fluids and take acetaminophen (Tylenol, others) to reduce your fever and body aches. Avoid nonsteroidal anti-inflammatory medications, including aspirin, which may not be safe in people with untreated meningitis. Also avoid any medications that may reduce your alertness.

Don’t go to work or school. Work with your doctor to get a diagnosis and find out if treatment is needed as soon as possible.

Tests and diagnosis

Your family doctor or pediatrician can diagnose meningitis based on a medical history, a physical exam and certain diagnostic tests. During the exam, your doctor may check for signs of infection around the head, ears, throat and the skin along the spine. You or your child may undergo the following diagnostic tests:

• Throat culture. A throat culture can find and identify the bacteria causing throat pain, neck pain and headache, but can’t determine what pathogens may be in your spinal fluid.
• Imaging. X-rays and computerized tomography (CT) scans of the chest, skull or sinuses may reveal swelling or inflammation. These tests can also help your doctor look for infection in other areas of the body that may be associated with meningitis.
• Spinal tap (lumbar puncture). The definitive diagnosis of meningitis is often made by analyzing a sample of your cerebrospinal fluid (CSF), which is collected during a procedure known as a spinal tap. In people with meningitis, the CSF fluid often shows a low sugar (glucose) level along with an increased white blood cell count and increased protein. CSF analysis may also help your doctor identify the exact bacterium that’s causing the illness. Traditionally, it can take up to a week to get these test results. In March 2007, the Food and Drug Administration approved the Xpert EV test, a test that takes only two and one-half hours. This test identifies any genetic material in the CSF from a class of viruses responsible for approximately 90 percent of viral meningitis cases. A positive test tells your doctor you likely have viral meningitis, and a negative test strongly suggests no viral meningitis, making the less common bacterial form of meningitis more likely. This can help those with viral meningitis avoid unnecessary treatment with antibiotics.
• Polymerase chain reaction analysis. If your doctor suspects meningitis, he or she may order a DNA-based test known as a polymerase chain reaction (PCR) amplification to check for the presence of certain causes of meningitis.

If you have chronic meningitis caused by cancer or an inflammatory illness, you may need additional tests.

Treatments and drugs

Bacterial meningitis
Acute bacterial meningitis requires prompt treatment with intravenous antibiotics to ensure recovery and reduce the risk of complications. The antibiotic or combination of antibiotics that your doctor may choose depends on the type of bacteria causing the infection. Often, analyzing a sample of cerebrospinal fluid can help identify the bacteria. If you or your child has bacterial meningitis, your doctor may recommend a broad-spectrum antibiotic until he or she can determine the exact cause of the meningitis.

If you or your child has bacterial meningitis, your doctor may recommend treatments for brain swelling, shock, convulsions or dehydration. Infected sinuses or mastoids — the bones behind the outer ear that connect to the middle ear — may need to be drained. Any fluid that has accumulated between the brain and the membranes that surround it may also need to be drained or surgically removed.

Viral meningitis
Antibiotics can’t cure viral meningitis, and most cases improve on their own in a week or two without therapy. Treatment of mild cases of viral meningitis is usually with bed rest, plenty of fluids and over-the-counter pain medications to help reduce fever and relieve body aches. If the cause of your meningitis is the herpes virus, your doctor may also recommend an antiviral medication aimed at this virus.

Prevention

Meningitis typically results from contagious infections. Common bacteria or viruses that can cause meningitis can spread through coughing, sneezing, kissing or sharing eating utensils, a toothbrush or a cigarette. You’re also at increased risk if you live or work with someone who has the disease.

These steps can help prevent meningitis:

• Wash your hands. Careful hand washing is important to avoiding exposure to infectious agents. Teach your children to wash their hands often, especially before they eat and after using the toilet, spending time in a crowded public place or petting animals. Show them how to wash their hands vigorously, covering both the front and back of each hand with soap and rinsing thoroughly under running water.
• Stay healthy. Maintain your immune system by getting enough rest, exercising regularly, and eating a healthy diet with plenty of fresh fruits, vegetables and whole grains.
• Cover your mouth. When you need to cough or sneeze, be sure to cover your mouth and nose.
• If you’re pregnant, take care with food. Reduce your risk of listeriosis if you’re pregnant by cooking meat thoroughly and avoiding cheeses made from unpasteurized milk.

Immunizations
Some forms of bacterial meningitis are preventable with the following vaccinations:

• Haemophilus influenzae type b (Hib) vaccine. Children in the United States routinely receive this vaccine as part of the recommended schedule of vaccines, starting at about 2 months of age. The vaccine is also recommended for some adults, including those who have sickle cell disease or AIDS and those who don’t have a spleen.
• Pneumococcal conjugate vaccine (PCV7). This vaccine is also part of the regular immunization schedule for children younger than 2 years in the United States. In addition, it’s recommended for children between the ages of 2 and 5 who are at high risk of pneumococcal disease, including children who have chronic heart or lung disease or cancer.
• Pneumococcal polysaccharide vaccine (PPV). Older children and adults who need protection from pneumococcal bacteria may receive this vaccine. The Centers for Disease Control and Prevention recommends the PPV vaccine for all adults older than 65 and younger adults and children who have weak immune systems, chronic illnesses such as heart disease, diabetes or sickle cell anemia, and those who don’t have a spleen.
• Meningococcal conjugate vaccine (MCV4). The Centers for Disease Control and Prevention recommends that a single dose of MCV4 be given to children ages 11 to 12 or to any children ages 11 to 18 who haven’t yet been vaccinated. However, this vaccine can be given to younger children who are at high risk of bacterial meningitis or who have been exposed to someone with the disease. It’s approved for use in children as young as 2 years old.

Mesothelioma

Definition

Malignant mesothelioma (me-zo-thee-le-O-muh) is a rare cancer that occurs in the thin layer of tissue that covers the majority of your internal organs (mesothelium).

Doctors divide mesothelioma into different types based on what part of the mesothelium is affected, including:

• Pleural malignant mesothelioma, which affects the tissue that surrounds the lungs and is the most common form of mesothelioma.
• Peritoneal mesothelioma, which occurs in the tissue in your abdomen.
• Pericardial mesothelioma, which affects the tissue surrounding the heart.
• Mesothelioma of the tunica vaginalis, which occurs in the lining around the testicles.

Between 2,000 and 3,000 people are diagnosed with mesothelioma in the United States each year, according to the American Cancer Society.

Symptoms

Signs and symptoms of mesothelioma vary depending on where the cancer occurs.

Pleural mesothelioma signs and symptoms may include:

• Shortness of breath
• Painful breathing (pleurisy)
• Painful coughing
• Chest pain under the rib cage
• Unusual lumps of tissue under the skin on your chest
• Unexplained weight loss
• Dry (nonproductive) cough

Peritoneal mesothelioma signs and symptoms may include:

• Abdominal pain
• Abdominal swelling
• A change in your bowel habits, such as more frequent diarrhea or constipation
• Lumps of tissue in the abdomen
• Unexplained weight loss

Other forms of mesothelioma
Signs and symptoms of pericardial mesothelioma and mesothelioma of the tunica vaginalis are unclear. These forms are so rare that not much information is available. Pericardial mesothelioma signs and symptoms may include difficulty breathing or chest pains. Mesothelioma of the tunica vaginalis may be first detected as a mass on a testicle.

When to see a doctor
See your doctor if you have signs and symptoms that may indicate mesothelioma. Signs and symptoms of mesothelioma aren’t specific to this disease and, due to the rarity of mesothelioma, are more likely to be related to other conditions. If any persistent signs and symptoms seem unusual or bothersome to you, ask your doctor to evaluate them.

Causes

In general, cancer begins when a series of genetic mutations occur within a cell, causing the cell to grow and multiply out of control, when healthy cells would normally die. The accumulating abnormal cells form a mass (tumor). Cancer cells invade nearby tissues and can break off from an initial tumor to spread elsewhere in the body (metastasize).

It isn’t clear what causes the initial genetic mutations that lead to mesothelioma, though researchers have identified factors that may increase the risk. It’s likely that cancers form because of an interaction between many factors, such as inherited conditions, your environment, your health conditions and your lifestyle choices.

Benign pleural mesothelioma
A form of noncancerous (benign) tumor that can occur in the chest is sometimes called benign mesothelioma. However, this name is misleading. Benign mesothelioma doesn’t begin in the same cells where the cancerous forms of mesothelioma begin. And, in a minority of cases, benign mesothelioma can be very aggressive, despite the term “benign.” For this reason, some doctors now refer this tumor as solitary fibrous tumor.

Solitary fibrous tumor usually doesn’t cause signs and symptoms. Most cases are inadvertently discovered during tests and procedures for other conditions. It isn’t clear what causes solitary fibrous tumors, but they aren’t linked to asbestos exposure. Treatment for solitary fibrous tumor typically includes surgery.

Risk factors

Asbestos exposure: The primary risk factor for mesothelioma
Asbestos is a mineral that’s found naturally in the environment. Asbestos fibers are strong and resistant to heat, making them useful in a wide variety of applications, such as in insulation, cement, brakes, shingles, flooring and many other products. People who work around asbestos fibers are thought to have the greatest risk of mesothelioma.

When asbestos is broken up, such as during the mining process or when removing asbestos insulation, dust may be created. If the dust is inhaled or swallowed, the asbestos fibers may settle in the lungs or in the stomach, where they can cause irritation that may lead to mesothelioma, though how exactly this happens isn’t understood.

Mesothelioma risk is believed to be increased in people who are exposed to high levels of asbestos, in people who are exposed to asbestos over a long period of time and in people exposed to asbestos at a young age. It can take 30 to 40 years or more for mesothelioma to develop as a result of asbestos exposure.

Some people with years of asbestos exposure never develop mesothelioma. And yet, others with very brief exposure develop the disease. This indicates that other factors may be involved in determining whether someone gets mesothelioma or doesn’t. For instance, you could inherit a predisposition to cancer or some other condition could increase your risk.

Possible risk factors
Factors that may increase the risk of mesothelioma include:

• Personal history of asbestos exposure. If you’ve been directly exposed to asbestos fibers at work or at home, your risk of mesothelioma is greatly increased.
• Living with someone who works with asbestos. People who are exposed to asbestos may carry the fibers home on their skin and clothing. These stray fibers can put others in the home at risk of mesothelioma. People who work with asbestos should shower and change clothes before leaving work.
• Smoking. Risk of mesothelioma is increased greatly in smokers who are exposed to asbestos.
• SV40. Some research indicates a link between mesothelioma and simian virus 40 (SV40), a virus originally found in monkeys. Millions of people may have been exposed to SV40 when receiving polio vaccinations between 1955 and 1963, because the vaccine was developed using monkey cells. Once it was discovered that SV40 was linked to certain cancers, the virus was removed from the polio vaccine. Whether SV40 increases the risk of mesothelioma is a point of debate, and more research is needed.
• Radiation. Some research links mesothelioma to the radioactive substance thorium dioxide, which was used along with X-rays to diagnose various health conditions from the 1920s to the 1950s. Thorium dioxide was later found to cause cancer and is no longer used.
• Family history. A family history of mesothelioma may increase your risk of mesothelioma, but more research is needed to understand this theory.

Complications

Complications from spreading cancer
As pleural mesothelioma spreads in the chest, it puts pressure on the structures in that area. This can cause complications, such as:

• Difficulty breathing
• Chest pain
• Difficulty swallowing
• Swelling caused by pressure on the large vein that leads from your upper body to your heart (superior vena cava syndrome)
• Pain caused by pressure on the nerves and spinal cord
• Accumulation of fluid in the chest (pleural effusion), which can compress the lung nearby and make breathing difficult

Death
Mesothelioma that progresses can lead to death. People who die of mesothelioma usually die from related complications, such as lung failure, heart problems, stroke and other causes.

Preparing for your appointment

You’re likely to start by first seeing your family doctor or a general practitioner. However, in some cases when you call to set up an appointment, you may be referred immediately to a doctor who specializes in lung diseases (pulmonologist) or abdominal problems (gastroenterologist).

Because appointments can be brief, and because there’s often a lot of ground to cover, it’s a good idea to be well prepared for your appointment. Here’s some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there’s anything you need to do in advance, such as restrict your diet.
• Write down any symptoms you’re experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes. If you’re worried about mesothelioma, make a list of all your occupations, even those you had for only a few months.
• Make a list of all medications, as well as any vitamins or supplements, that you’re taking.
• Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out. For mesothelioma, some basic questions to ask your doctor include:

• What is likely causing my symptoms or condition?
• What are other possible causes for my symptoms or condition?
• What kinds of tests do I need?
• Is my condition likely temporary or chronic?
• What is the best course of action?
• What are the alternatives to the primary approach that you’re suggesting?
• I have these other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow?
• Should I see a specialist? What will it cost, and will my insurance cover seeing a specialist?
• Is there a generic alternative to the medicine you’re prescribing me?
• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend?
• What will determine whether I should plan for a follow-up visit?

In addition to the questions that you’ve prepared to ask your doctor, don’t hesitate to ask questions during your appointment at any time that you don’t understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may allow more time to cover other points you want to address. Your doctor may ask:

• When did you first begin experiencing symptoms?
• Have your symptoms been continuous, or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Do your symptoms affect your ability to work?

What you can do in the meantime
Try to avoid anything that worsens your signs and symptoms. For instance, if you’re experiencing shortness of breath, try to take it easy until you can meet with your doctor.

Tests and diagnosis

If you have signs and symptoms that might indicate mesothelioma, your doctor will conduct a physical exam to check for any lumps or other unusual signs. Your doctor may order imaging scans, such as a chest X-ray or a computerized tomography (CT) scan of your chest or abdomen, to look for abnormalities.

It’s not uncommon for mesothelioma to be misdiagnosed initially because mesothelioma is rare, and its signs and symptoms aren’t specific. Your doctor will likely rule out other more common conditions before considering mesothelioma.

Biopsy
Biopsy, a procedure to remove a small portion of tissue for laboratory examination, is the only way to determine whether you have mesothelioma. Depending on what area of your body is affected, your doctor selects the right biopsy procedure for you. Options include:

• Fine-needle aspiration. The doctor removes fluid or a piece of tissue with a small needle inserted into your chest or abdomen.
• Thoracoscopy. Thoracoscopy allows the surgeon to see inside your chest. In this procedure, the surgeon makes one or more small incisions between your ribs. A tube with a tiny video camera is then inserted into your chest cavity — a procedure sometimes called video-assisted thoracoscopic surgery (VATS). Special surgical tools allow your surgeon to cut away tissue for testing.
• Laparoscopy. Laparoscopy allows the surgeon to see inside your abdomen. Using one or more small incisions into your abdomen, the surgeon inserts a tiny camera and special surgical tools to obtain a small piece of tissue for examination.
• Thoracotomy. Thoracotomy is surgery to open your chest between the ribs to allow a surgeon to check for signs of disease. He or she removes a sample of tissue for testing.
• Laparotomy. Laparotomy is surgery to open your abdomen to allow a surgeon to check for signs of disease. He or she removes a sample of tissue for testing.

The tissue sample is analyzed under a microscope to see whether the abnormal tissue is mesothelioma and what types of cells are involved. The type of mesothelioma you have determines your treatment plan.

Staging
Once mesothelioma is diagnosed, your doctor orders other tests to determine the extent, or stage, of the cancer. Imaging tests that may help determine the stage of your cancer include:

• Chest X-ray
• CT scans of the chest and abdomen
• Magnetic resonance imaging (MRI)
• Positron emission tomography (PET)

Once the extent of pleural mesothelioma is determined, a stage is assigned. Formal stages aren’t available for other types of mesothelioma because these types are rare and aren’t well studied. The stages of pleural mesothelioma are:

• I. Stage I pleural mesothelioma is considered localized cancer, meaning it’s limited to one portion of the lining of the chest.
• II. Stage II mesothelioma may have spread beyond the lining of the chest to the diaphragm or to a lung.
• III. Stage III mesothelioma may have spread to other structures within the chest and may involve nearby lymph nodes.
• IV. Stage IV mesothelioma is an advanced cancer that has spread to distant areas (metastasized). Mesothelioma most commonly spreads (metastasizes) to the brain, lymph nodes in the chest and areas of the lung that are away from the tumor.

Treatments and drugs

What treatment you undergo for mesothelioma depends on your health and certain aspects of your cancer, such as its stage and location. Unfortunately, mesothelioma often is an aggressive disease and for most people a cure isn’t possible. Mesothelioma is usually diagnosed at an advanced stage — when it isn’t possible to remove the cancer through an operation. Instead, your doctor may work to control your cancer to make you more comfortable.

Discuss treatment goals with your doctor. Some people want to do everything they can to treat their cancer, even if that means enduring side effects for a small chance of an improvement. Others prefer treatments that make them comfortable so that they can live their remaining months as symptom-free as possible.

Surgery
Surgeons work to remove mesothelioma in instances where it is diagnosed at an early stage. Sometimes it isn’t possible to remove all of the cancer. In those cases, surgery may help to reduce the signs and symptoms caused by mesothelioma spreading in your body. Surgical options may include:

• Surgery to decrease fluid buildup. Pleural mesothelioma may cause fluid to build up in your chest, causing difficulty breathing. Surgeons insert a tube or catheter into your chest to drain the fluid. Surgeons may also inject medicine into your chest to prevent fluid from returning (pleurodesis).
• Surgery to remove the tissue around the lung or abdomen. Surgeons may remove the tissue lining the ribs and the lungs (pleurectomy) or the tissue lining the abdominal cavity (peritonectomy) in order to relieve signs and symptoms of mesothelioma.
• Surgery to remove as much of the cancer as possible (debulking). If all of the cancer can’t be removed, surgeons may attempt to remove as much as possible.
• Surgery to remove a lung and the surrounding tissue. Removing the affected lung and the tissue that surrounds it may relieve signs and symptoms of pleural mesothelioma. This procedure also allows doctors to use higher doses of radiation against any remaining mesothelioma, since they won’t need to worry about protecting your lung from damaging radiation.

Chemotherapy
Chemotherapy uses chemicals to kill cancer cells. Systemic chemotherapy travels throughout the body and may shrink or slow the growth of a pleural mesothelioma that can’t be removed using surgery. Chemotherapy may also be used before surgery (neoadjuvant chemotherapy) to make an operation easier or after surgery (adjuvant chemotherapy) to reduce the chance that cancer will return.

Chemotherapy drugs may also be heated and administered directly into the abdominal cavity (intraperitoneal chemotherapy), in the case of peritoneal mesothelioma, or into the chest cavity (intrapleural chemotherapy), in the case of pleural mesothelioma. Using this strategy, chemotherapy drugs can reach the mesothelioma directly without injuring healthy cells in other parts of the body. This allows doctors to administer higher doses of chemotherapy drugs.

Intraperitoneal chemotherapy may also be used to reduce the signs and symptoms of peritoneal mesothelioma that can’t be removed through surgery.

Radiation therapy
Radiation therapy focuses high-energy beams to a specific spot or spots on your body. Radiation may reduce signs and symptoms in people with pleural mesothelioma. Doctors aim radiation at the entire chest to obtain the best result. However, many sensitive organs are in the chest, such as the heart, lungs, esophagus and spinal cord, so doctors must use low doses of radiation to spare these organs. Radiation therapy is sometimes used after biopsy or surgery to prevent mesothelioma from spreading to the surgical incision.

Radiation therapy is used occasionally in people with peritoneal mesothelioma to reduce signs and symptoms caused by the cancer.

Combination therapy
Surgery, chemotherapy and radiation therapy may be combined. This aggressive therapy can be grueling and may not be appropriate for everyone. Younger, healthier people and those with earlier stage mesothelioma may be more able to endure this treatment. Combination therapy has shown the most promise in treating mesothelioma. However, most people will eventually experience a recurrence of this cancer despite aggressive treatment. Combination therapy has been used in both pleural mesothelioma and peritoneal mesothelioma.

Clinical trials
Clinical trials are studies of new mesothelioma treatment methods. People with mesothelioma may opt for a clinical trial for a chance to try new types of treatment. However, a cure isn’t guaranteed. Carefully consider your treatment options and talk to your doctor about what clinical trials are open to you. Your participation in a clinical trial may help doctors better understand how to treat mesothelioma in the future.

Clinical trials are currently investigating a number of targeted drugs. Targeted drug therapy uses drugs to attack specific abnormalities within cancer cells. Targets being studied in mesothelioma include a substance that cancer cells make to attract new blood vessels to bring the cancer oxygen and nutrients. Another target is an enzyme that helps cancer cells develop resistance to chemotherapy drugs. Researchers hope drugs that target these areas can help kill mesothelioma cells.

Treatment for other types of mesothelioma
Pericardial mesothelioma and mesothelioma of the tunica vaginalis are very rare and can be very aggressive. Early-stage cancer may be removed through surgery. Doctors have yet to determine the best way to treat later stage cancers, though. Your doctor may recommend other treatments to improve your quality of life.

Alternative medicine

No alternative medicine treatments have proved helpful in treating mesothelioma. But complementary and alternative mesothelioma treatments may help control signs and symptoms. Discuss options with your doctor.

Mesothelioma can cause pressure within your chest that can make you feel as though you’re always short of breath. Breathlessness can be distressing. Your doctor may recommend using an oxygen mask or taking medications to make you more comfortable, but often these aren’t enough. Combining your doctor’s recommended treatments with complementary and alternative approaches may help you feel better.

Alternative treatments that have shown some promise in helping people cope with breathlessness include:

• Acupuncture. Acupuncture uses thin needles inserted at precise points into your skin.
• Breath training. A nurse or physical therapist can teach you breathing techniques to use when you feel breathless. Sometimes you may feel breathless and begin to panic. Implementing these techniques may help you feel more in control of your breathing.
• Relaxation exercises. Slowly tensing and relaxing different muscle groups may help you feel more at ease and breathe easier. Your doctor may refer you to a therapist who can teach you relaxation exercises so that you can do them on your own.
• Sitting near a fan. Directing a fan to your face may help ease the sensation of breathlessness.

Coping and support

A diagnosis of mesothelioma can be devastating not only to you, but also to your family and friends. Take time to experience the sadness and despair and to grieve. And remember that you decide how you’ll spend your time and with whom you’ll spend it.

In order to regain a sense of control, try to:

• Learn everything you can about mesothelioma. Write down a list of questions to ask your doctor. Ask your health care team for information to help you better understand your disease. Consult the National Cancer Institute (NCI) and the American Cancer Society (ACS). Both organizations have Web sites and toll-free telephone information lines. Call the NCI at 800-4-CANCER (800-422-6237). Call the ACS at 800-ACS-2345 (800-227-2345).
• Surround yourself with a support network. Close friends or family can help you with everyday tasks, such as getting you to appointments or treatment. If you have trouble asking for help, learn to be honest with yourself and accept help when you need it.
• Seek out other people with cancer. Ask your health care team about cancer support groups in your community. Sometimes there are questions that can only be answered by other people with cancer. Support groups offer a chance to ask these questions and receive support from people who understand your situation. Online support message boards, such as the ACS’s Cancer Survivors Network, can offer similar benefits while allowing you to remain anonymous.
• Plan for the unknown. Ask your health care team about advance directives that give your family guidance on your medical wishes in case you can no longer speak for yourself. Talk to a lawyer about your will, if you haven’t already done so.

Prevention

Reducing your exposure to asbestos may lower your risk of mesothelioma.

Find out whether you work with asbestos
Most people with mesothelioma were exposed to the asbestos fibers at work. Workers who may encounter asbestos fibers include:

• Miners
• Factory workers
• Insulation manufacturers
• Railroad workers
• Ship builders
• Gas mask manufacturers
• Construction workers
• Auto mechanics

Ask your employer whether you have a risk of asbestos exposure on the job.

Follow your employer’s safety regulations
Follow all safety precautions in your workplace, such as wearing protective equipment. You may also be required to shower and change out of your work clothes before taking a lunch break or going home. Talk to your doctor about other precautions you can take to protect yourself from asbestos exposure.

Be safe around asbestos in your home
Older homes and buildings may contain asbestos. In many cases, it’s more dangerous to remove the asbestos than it is to leave it intact. Breaking up asbestos may cause fibers to become airborne, where they can be inhaled. Consult experts trained to detect asbestos in your home. These experts may test the air in your home to determine whether the asbestos is a risk to your health. Don’t attempt to remove asbestos from your home — hire a qualified expert. The Environmental Protection Agency offers advice on its Web site for dealing with asbestos in the home.