Dr. Vallieres summarizes his tri-modal treatment therapy program

"Well, it's not my own, but it was something that I thought of with my oncologist and my radiation oncologist at the University of Washington when I moved there in '96.

This is actually something I had already tried on a few patients before when I was in Canada; an idea of giving these patients a chemotherapy first, then taking them to surgery and proceed with as radical of an operation as we can do, and then treat their hemithorax with radiation therapy, so combining the best of these three common modalities of treatment -- of cancer treatment, trying to get the best out of each.

It's one of the trimodal therapies. The sequence that we have used here in Seattle for the last eight years has been chemo first, followed by surgery, followed by radiation.

Elsewhere in the country, they will also label them trimodal therapy, but they will start with surgery first and then follow with chemo and radiation."

"...it's a cancer of the envelopes around the lung. So to remove all of these envelopes, you have to stay outside of that envelope.

So you kind of peal off the envelope from the underside of the rib, do the same thing as you come around the mediastinal compartment here.

Dr. Vallieres Describes the EPP Surgical Procedure and Post Surgical Radiotherapy

Unfortunately, you cannot peal off the pleura from the diaphragm. It just doesn't happen. So you have to remove the diagram with the lung in order to remove these envelopes. I'll come back to this.

Then the pericardium, which is the envelope around the heart, similarly, you cannot peel off the pleura from the pericardium. So in an effort to remove all of the envelopes where the cancer is, you also have to remove part of the pericardium, which is that envelope that is around the heart.

Now, the diaphragmatic part, it's important because the bulk of the disease in these patients is usually found in the most dependent portion of their chests, in the bottoms. So it's very important that, if you want to be clean and try to remove as much of the cancer cells as possible, at least I believe that you need to remove the diaphragm so that you don't leave any behind."

The commonest complication is fatigue, and in all fairness, I don't think it's due to the radiation alone as much as the fact that these patients have now been treated for six or seven months.

They are tired. They have had chemo for awhile, then they get surgery, and they recover, and just as they are recovering, bang, we come in with the radiation. So I think that is one thing. Fatigue, depression settles into most patients.

Because of the esophagus, which is the swallowing tube, travels right outside of where that pleura was, that esophagus gets radiated. So patients get a certain degree of sunburn in their esophagus, which is transient, but affects their ability to eat and swallow for while at a crucial time when we are trying to have them recover from all of this.

Pain; not sure why, but pain has been an issue in a lot of our patients as a result of the radiation treatment. They are doing well after surgery, their pain is under good control, it's getting better; they get the radiation, wow, pain flairs up, and I'm not sure why that is.

Less common complication is, particularly in this scenario of after an extrapleural pneumonectomy is pneumonitis where the other lung gets an inflammation.

There is an inflammation that occurs in the other lung, which is probably not related solely to an effect of the radiation on that lung itself, but more to a reaction that occurs in the body, and it affects the other lung. That's not uncommon, but it does occur, and these are the four common things that you see after radiation therapy."

Dr. Vallieres on Complications from Pleural Mesothelioma and Recurrence

"Well, if their predominate site of recurrence or failure is inside the hemi chest, it usually involves the mediastinal middle compartment where the lymph nodes are, and there are some vital structures that travel in that area.

There is the esophagus, the swallowing tube. There is the trachea. There are veins that lead in and out of the heart, leading in for the vena cava. The aorta is not an issue. There are the pulmonary veins, as well.

So these structures are compressible. You can compress them. So if there is a fair amount of recurrence near the mediastinal, these patients may present with compression of these structures. If you compress the esophagus, you can't eat. If you compress the airway, initially all you do is you wheeze, but eventually you can't breathe. If you compress the veins, then the venous return to the heart is comprised, and so is the heart function.

The heart itself, if they fail within the pericardial sack, then the heart has nowhere to pump.

So that's an issue. They die of heart failure related to this recurrence.

That really is what the local regional failures -- patients, that's how they die. Patients who present with systemic metastases, cancer elsewhere outside of the box where we operated and radiated, they have -- they tend to have more of a cancer death, which is more of a weight loss, weaker body, weaker immune system, infections, and death, just one of these so-called cachectic death where it's not really one particular thing that is happening; it's just a slow demise."

So metastatic disease, that's usually the way they die. Local regional disease is the former group.

Dr. Vallieres on Pain Genesis and Control

"It depends on where -- you know, if all of the cancer does is it recurs in the other lung and does not invade any sensitive structures, then they don't have any pain from it. They just slowly die.

But if it involves their chest wall, there's a recurrence in their chest wall or elsewhere in the body where there are some sensitive fibers, then that can be a fairly severe pain that hopefully we can control with medication, orally, intravenously, patches.

If that doesn't work, sometimes we will give palliative radiation to that area to try to minimize their pain, but that can be an awful way to go, as well, and I've seen that in some patients with mesothelioma."

 Dr. Vallieres on the treatment options for Bob Treggett

"Well, at the time -- this was back in the late 2003, Alimta, which is the chemotherapy drug I was alluding to earlier, was not available outside of a research protocol.

So my opinion, he only had -- he had three options. One was no treatment at all, which was not a great option. Second option was a chemotherapy option, combining different agents that were available at the time, and when Alimta was to become available, we could have switched him to Alimta.

Alimta at the time, by the way, was also available on a compassionate drug use program through the company that makes the drug, Lilly Oncology. So if the oncologist that he was being treated with was willing to do that paperwork, that was available.

Then the third option was an option that offered some form of surgical procedure to him. I discussed with him pleurectomy, which is one operation that I don't do, I don't favor, but other experts with mesothelioma believe is a good operation, where all you do is you remove the lining. You don't remove the whole lung. You just remove all that lining around that has the disease.

And then the option I favored was an option, since he had early disease, he appeared to have good physiological reserve that would allow him to tolerate this aggressive treatment, I told him that, if you want to treat this aggressively, he could receive pre-op chemotherapy, followed by surgery, followed by hemithorax radiation, and I explained to him what the rationale behind those three modalities were."

 Dr. Vallieres on Bob Treggett's Surgery and Complications

"Not during the procedure itself, but if I recall, about day two or three after the surgery, he had atrial fibrillation, which is unfortunately too common of a problem that we see after the surgery.

What this is is a rhythm issue with their heart. The right -- the atrial portion of their heart starts racing on them.

He also developed a left-sided pleural effusion early after surgery, within the first week, that we had to have the radiologist dry out a few times under ultrasound guidance, and this fluid kept coming back. There was no evidence of cancer causing this. I wasn't sure why it was happening, but eventually what I did is I put in a small catheter in his left side so that he could drain himself out at home, and so we didn't have to keep him in the hospital just to manage that fluid issue."

"... about day three, he just had a very bad day, and I recall it because he looked so good the first couple of days, and then day three, he took a hit pain-wise, and then -- I wasn't surprised because it's kind of the common way these patients behave after surgery, but he looked so good for the first few days, and day three I recall he just didn't look as good."