I'm Laura Magson, I'm a solicitor at Boyes Turner and would like to welcome you all and many thanks for listening in today
I'm joined by Samantha Westbrook when we started organizing our annual study day last year I approached a number of speakers including Samantha who kindly agreed to talk about eight months ago now at our mesothelioma and lung cancer study day. I don't think anybody expected that that study day wouldn't be able to go ahead face to face in our offices as planned but nevertheless we've we've had to adapt. Samantha has kindly agreed to do a short webinar instead.
For those that don't know Samantha Westbrook is a peritoneal clinical nurse specialist at the peritoneal malignancy Institute at Basingstoke Hospital, her post has been funded by Mesothelioma UK since I think September 2018, it's a charity that's fantastic, it's nationwide and dedicated to Mesothelioma patients thank you Sam for carrying on in these unprecedented times I'll hand over to you now Samantha if you'd like to tell everybody what you're going to talk about today?
Oh hi good morning, hi Laura thank you for the kind introduction so in this one I'm going to talk to you about peritoneal mesothelioma I'm going to give you a little bit of an overview of peritoneal mesothelioma. We're going to look at the current landscape and what that looks like in the UK for the patients with peritoneal mesothelioma and then I'm going to touch on what what the future might hold and looking ahead a little bit more so I'm going to share my presentation with you.
So these are the numbers that have been recently published by the mesothelioma audit if we look at the statistics here there are about just over 7,000 patients in the UK diagnosed with mesothelioma in the two-year period this is 2016 2 18 of those about 260 cases are peritoneal mesothelioma and we can see here that the mean median age is around 71 there are more males and females but there are slightly more females than the males within the patient cases, this audit really showed the great work that's being done by the charities by the other hospitals with the National MDT's and all the regional NZ teas and in particular for us it showed that there was a doubling
of referrals to our national parents
know mesothelioma NDT from the previous
two years so that's a great achievement
for patients who are seeking that expert
advice and let's have a look at what
peritoneal mesothelioma is it's the
lining of the abdomen is the peritoneum
and what happens is the perineum
thickens when mesothelioma is present
and during that thickening it causes
fluid to collect now this fluid is
called ascites and when that happens the
abdomen swells the patient can be quite
uncomfortable with all that fluid there
there are two linings
there's the lining that's the visceral
lining which is next to the abdominal
organs and as the prize for lining that
lines the abdominal wall now personal
mesothelioma spreads outwards and around
it doesn't spread within it doesn't
infiltrate and it isn't him illogical
spread either it's quite unusual to see
the lymph glands affected by it and to
see any metastases out of the abdominal cavity it's very rare and it's very
uncommon at the moment we don't know of
any cure and and there are some thoughts
on how music a glioma guess for the
peritoneum and one thought is that be
crystals are ingested and slowly over
time they migrate from the lumen of the
GI tract to the peritoneum and the
latency period is slightly shorter than
that of the pleural mesothelioma
and that's been documented about around
20 years there are some documented cases
as long as Vestas causes of peritoneal mesothelioma
some say that radiation causes it so
that's the directly irradiated tissues
there's issue instances of recurrence
peritonitis and so patients who have
relapsing diverticulitis or patients with crohn's disease genetic dispositions and also and a virus called simian virus for T so if we look at peritoneal mesothelioma it's it's actually classified into some different subtypes we can put a couple into the low-grade spectrum and we can put some into what we call the higher grades and malignant spectrum in the low-grade we see
something called multi system is the video map and well-differentiatedPapillion is Aloma and in the high-grade malignant spectrum we see epithelioid and also chromatids and our biphasic and a distribution and the sites of disease can vary between each patient so the multi cystic is an a low-grade borderline malignant tumor it rarely spreads outside the afternoon and it does have high rates of recurrence
locally at the well differentiated papillary is even rarer we don't see
many of those patients with with this
and it's slightly more frequent in the
personally in the plural
our most common is the epithelial age
and slightly more rare is the Stockholm
it's weight and the biphasic the
patients often have a delayed diagnosis
and this is due to his symptoms being fairly nonspecific symptoms rather
common symptoms and that you could put
down to perhaps more and
more common issues so we have things
like Domino paintings we have abdominal swellings change in bowel habits Teagan weight
loss perhaps the patient has had a hernia and loss of appetite so quite sort of nonspecific some red flags there
for cancer symptoms and patients often go down different diagnostic pathways
and before they get to this diagnosis and sadly the patients do present at a an advanced tumor stage so how do we
diagnose it well often patients would have had a CT scan and for us when we're looking at CT scan is extremely important to look at the small bowel using this CT and we want to an almost estimate the degree of disease on the small bowel and and and that can tell us what and surgical options are available pet and CT scans yet show us superiority
over the CT scans diagnostic laparoscopy
is are something that we use to look at
08:05
the disease distribution and estimate
08:08
the volume of disease and take biopsies
08:12
you can aspirate the ascites so that
08:15
fluid in the abdominal cavity we were
08:17
talking about earlier and that that that
08:19
can be helpful and but often it's non
08:21
diagnostic to give us a diagnosis of
08:24
peritoneal mesothelioma there are
08:32
options of treatment pathways and some
08:36
patients go onto a surveillance program
08:37
where we watch the disease they have
08:41
scans they will interview interval scans
08:44
over a period of time just watching the
08:47
disease some patients opt to have a
08:50
chemotherapy and and some perhaps would
08:53
consider having a surgery there are
08:56
clinical trial options available as well
08:59
and for patients who perhaps not
09:02
suitable for surgery or have had a
09:03
couple of
09:04
lines of chemotherapies so we just have
09:10
a quick look at the history NHS England
09:15
in 2015
09:17
made the decision not to routinely
09:19
commissioned surgery for peritoneal
09:22
mesothelioma the surgery that we do at
09:24
Basingstoke is called cytoreductive
09:27
surgery and hyperthermic chemotherapy we
09:33
shorten that Cirrus and HIPEC because
09:35
it's a bit of a mouthful to say all the
09:37
time and they the standard treatment is
09:41
is the chemotherapy now we have we have
09:47
a special interest in personal
09:49
mesothelioma amazing stick and music UK
09:52
in particular as well and in March 2016
09:57
the team decided to set up a national
10:00
personally glioma mzt meeting and
10:03
essentially they wanted to look at and
10:06
gain a consensus on what treatment
10:10
advice they can give and to look at
10:12
trends and how patients do over time
10:16
collecting their evidence and looking at
10:19
the data and the decision was made to
10:22
continue offering the surgery for
10:25
personal mesothelioma at our Hospital so
10:31
the MDT looks a bit like this it's a is
10:34
this a virtual MDT bit like what we're
10:37
all used to at the moment we have the
10:40
peritoneal malignancy surgeons at Good
10:43
Hope in Birmingham dial in and the
10:47
matter in Dublin dial in as well we have
10:51
expert pathologist who is well known in
10:56
in looking at personally see glioma we
10:59
have specialist nurse we have our
11:01
radiologist we have an oncologist and
11:03
our NDT coordinator collects all the
11:05
information for the meeting and we
11:08
review all the histology so we ask for
11:10
all the tissue blocks than the biopsies
11:14
to be sent to us for our pathologist her
11:17
have a look and to give a second opinion
11:19
all the images are reviewed we look at
11:22
the clinical information we might have
11:25
DVDs of laparoscopy that have been done
11:28
in the local hospitals or pictures for
11:30
us to look at I myself may have spoken
11:34
to the patient specialist nurse in their
11:37
local hospital or I might have actually
11:39
spoken to the patients or the families
11:40
themselves acting on their behalf and
11:42
knowing their wishes we recommend a
11:46
treatment pathway and that may be seeing
11:49
on an oncologist or it may be looking at
11:52
other any clinical trials available or
11:55
it may be looking at assessing them for
11:57
the suitability for the surgery it just
12:03
popped in a table here we recently
12:05
published a paper of our MD T and it is
12:09
it's interesting to have a look at the
12:11
number of cases that we looked at the
12:14
majority as we know the most common
12:16
epithelioid news Vienna followed by the
12:19
multi cystic and in the biphasic s--
12:22
after that and what we found from the
12:25
data was that patients who received the
12:29
Cirrus and HIPEC surgery showed a better
12:32
of one two and three year overall
12:34
survival and those were in patients that
12:37
were carefully selected through this MDT
12:39
process so what does the e surgery
12:44
involve well completely removing on this
12:47
tumor we call a complete site reduction
12:49
and its aims to remove all of that
12:51
macroscopic tumor but it can come with
12:55
its complications such as hemorrhages or
12:58
fish to lose perforations the wounds not
13:01
healing or abscesses and and at times we
13:05
can offer operations to remove a bulk of
13:09
disease perhaps if that's causing
13:11
problems for a patient discomfort pain
13:13
so we can help to remove disease that's
13:16
and causing symptoms there so in the
13:22
sugar bay
13:22
technique this is all the procedures
13:24
that are involved now not every patient
13:26
will have all of these procedures it's
13:29
specific to where their diseases so
13:32
right sides that the bowel can be
13:34
removed we would remove something called
13:37
the Ament 'm which is a fat apron but
13:39
over lays over the top of all of the
13:42
abdominal organs and we spleen may be
13:46
removed the gallbladder may be removed
13:49
patients may need a hysterectomy or
13:52
their ovaries removed we would strip the
13:56
peritoneum and strip the linings of the
13:58
diaphragm and perhaps the surface of the
14:03
liver and in some cases and there are
14:05
areas down in the rectum that needs to
14:07
be resected now the HIPEC is the heated
14:13
chemotherapy liquid and so this
14:16
addresses all the disease that we
14:17
perhaps can't see the macroscopic
14:19
disease we've removed all of the disease
14:21
that we can see with the crs and then
14:25
we're addressing the macroscopic disease
14:27
which is the chemotherapy wash now this
14:31
is isolated to the personal cavity it's
14:34
it's pumped in I'll show you the machine
14:37
on the next slide and it's left in the
14:40
cavity for about 60 minutes heated and
14:43
the organs are bathed and there's no
14:46
toxicity or side effects to the patient
14:49
and possible tiredness or nausea but you
14:54
would expect that after operation anyway
14:57
so this is what it looks like it's a
15:01
metal scaffolding there's built around
15:05
and then the tubes by the machine
15:08
pumping the hot chemotherapy wash in the
15:11
organs are bathed and then it's removed
15:16
for a patient who's undergoing this
15:19
surgery and this is sort of what their
15:22
initial journey might might look like on
15:26
the day of admission they'll come to us
15:28
two days before the actual operation
15:31
itself and all the usual paperwork's are
15:35
completed
15:36
now give them a liquid for a bell and to
15:39
clear out the boughs little pickle
15:41
accent she's a bowel prep and they will
15:44
be having clear fluids only and the day
15:49
before the operation is one of the
15:50
busier days actually so miss blue team
15:53
will come and see the patient and talk
15:56
to them we have dedicated stoma team who
16:00
come and see the patient so that's the
16:03
patient's who perhaps are having part of
16:05
their bowel removed and need to have a
16:07
bag on the outside on their tummy for
16:10
the stool to come out of that could be
16:12
either permanent or temporary the
16:16
anesthetist so the person who's putting
16:18
the patient to sleep and giving all the
16:20
sedation will come and see them we have
16:23
team of dieticians they will talk about
16:26
the artificial feeding that they'll be
16:30
getting for the first ten days and then
16:32
how they reintroduce food we have
16:35
physiotherapists and exercise
16:37
specialists and they will see the
16:39
patient really from the beginning and
16:41
out of the surgery and to get them up
16:44
and moving we offer them a visit to the
16:47
intensive care unit where they will stay
16:50
the first 24 hours minimum are to their
16:53
operation and the nurse myself I'll I'll
16:57
see the patient as well and we we talk
16:59
through all the ins and outs and what
17:00
what it might look like after the
17:02
operation and all those drains and the
17:04
drips that they that they will have and
17:07
on the day of the operation so they
17:09
don't have anything else to eat and
17:11
drink from midnight the night before and
17:13
they get woken up about 6 o'clock and
17:16
start getting getting ready a relative's
17:19
welcome to come and take them to the
17:21
operating theatre and the relatives will
17:25
receive two phone calls from the surgeon
17:27
during the day one usually just after
17:30
lunch and then one at the end these
17:34
patients do have complex care needs
17:36
after this operation often they would
17:39
have chest rings if they've had those
17:41
diaphragms stripped as I had mentioned
17:43
earlier they have multiple abdominal
17:46
drains to drain out any fluid
17:48
collections
17:50
they'd have to learn about this straight
17:51
macare if indeed they have a steamer all
17:54
patients do pain relief is one of our
17:57
big focuses so we really didn't want the
17:59
patients be any in any pain they'll have
18:02
an epidural in place and a button that
18:06
they can press to deliver extra
18:08
painkillers if they need it they are
18:12
ultimately artificially fed for around
18:14
ten days and like I said we we get the
18:18
patients up and moving very early on
18:21
sometimes patients will have the
18:23
chemotherapy wash after the operation as
18:27
well and that's what we shortened to
18:29
something called epic it's not always
18:32
done but it can be inserted through one
18:35
of those drains and left in under 24
18:38
hours and drained out the next day
18:41
now for a lot of patients this is an
18:45
emotional time and we recognize that and
18:48
so we do offer psychological support we
18:52
have a psychologist team for our
18:56
patients and they're screened before for
18:59
any anxiety and depression so that we're
19:02
able to support them the best we can
19:04
during this process and there are
19:07
various ways for us to get to know our
19:10
patients and this is something called
19:12
feeling out of Wankel this is me and we
19:15
can learn a little bit more about the
19:16
patient before they come and stay with
19:18
us and we offer inpatient Diaries as
19:21
well so there are a lot of worries and
19:27
concerns for these patients and I think
19:32
at the top of the list but for many and
19:34
which is an unsurprising is the
19:38
prognosis and what does this mean and
19:40
can we remove all of their tumor have we
19:44
got it all out how much longer will they
19:47
live for and so we have to support those
19:50
patients and try and answer those
19:52
questions as best we can the stoma can
19:55
be something that nobody particularly
19:58
wants and so we offer some counselling
20:00
for that the scar isn't
20:03
and see from the picture is a is a big
20:05
scar and for a lot of people that's
20:07
quite unsightly and it can take some
20:10
time to look at their belly button gets
20:12
removed during that process as well
20:13
which is quite unusual too when you look
20:16
down and see there's no belly button
20:19
so the scar can be a focus for a lot of
20:22
patients they're with us for about three
20:24
weeks and then afterwards when they go
20:27
home we offer a follow-up care so we do
20:31
telephone calls at certain points to
20:34
check that the patients are recovering
20:36
well at home and eleazar their local
20:39
teams so my role probably this bliss
20:46
isn't isn't exhaustive I support the
20:50
patients often remotely not only those
20:53
that are having this surgery but those
20:56
are going through all different
20:59
treatments in the UK I would signpost
21:03
them to various teams or various
21:07
services help them with any symptoms
21:12
that they are struggling with seeing if
21:14
there are all ways that we can help to
21:16
manage those speaking with their
21:18
specialist teams and their local
21:20
hospitals and specialist nurses and
21:26
often it can be talking about the
21:27
disease itself as we said that it's a
21:31
very rare disease and they find that
21:36
they want to talk to the people who have
21:39
experiencing in this service development
21:44
so we look at how we can improve our
21:47
treatments that were offering how can we
21:51
get it known what we're doing amazing
21:54
stake so I just thought I'd run through
21:59
a quick case study with you here just to
22:01
sort of set a bit more of a picture of
22:04
them perhaps what it might look like for
22:07
a patient
22:09
this referral came in last summer a
22:12
young female and with fit and well and
22:15
no medical history and she had they used
22:18
nonspecific symptoms that we spoke about
22:21
and was bit to handle something called
22:25
irritable bowel syndrome but these
22:28
didn't resolve and so she was referred
22:32
into the hospital and she had a
22:35
laparoscopy though this was her and
22:37
something to explore what might be going
22:40
on and inside the pelvic area looked
22:43
abnormal and so there was a biopsy that
22:45
was taken and this unfortunately came
22:49
back inconclusive and so no diagnosis
22:53
could be given so she went through a
22:55
second biopsy and that was reported as
22:59
the well differentiated papillary Parana
23:03
mesothelioma and that was the one that
23:06
we spoke about us it's in the low-grade
23:09
spectrum and she was informed by her
23:12
local team that this was something that
23:14
was low-grade and indolent and was
23:20
informed that her treatment options
23:22
could could bury and it could be either
23:24
the watch and wait or pass there might
23:26
be some chemotherapy or or an operation
23:28
might be needed so her local team
23:31
referred us referred her to us at our
23:34
national MDT and we had a look at that
23:36
in August and our pathologists had a
23:39
look and subtype t as epithelioid say
23:43
that moved it over into the malignant
23:46
spectrum and we do a particular test
23:52
calling ki-67 which is is slightly a
23:55
prognostic indicator and hers was around
23:58
20% around 9% is is that normal see
24:03
moving up higher is likely more
24:05
aggressive we had a look at her scans
24:09
which sewed quite extensive disease in
24:12
the in the lower part of in the pelvis
24:14
and their personal linings and also on
24:17
the diaphragm linings and we we
24:22
suggested that she'd
24:23
should consider some fertility options
24:27
and we had a look at the DVD from the
24:30
laparoscopy that was done in her local
24:33
Astra and it was quite difficult for us
24:34
to have a look on us to see the small
24:36
bowel and see if there was any disease
24:37
there so we decided we'd offer her our
24:42
patients appointment and we would do a
24:44
laparoscopy here at phasing snake and to
24:47
assess the disease so we did that in
24:50
October and it was decided that her
24:54
disease was operable and we'd be able to
24:56
achieve that full sight reduction and
25:00
that no bowel resections would be needed
25:02
and she'd in the meantime seen her
25:06
fertility team and her successful egg
25:09
collection so in November she had her
25:14
operation she had the CRS and HIPEC
25:17
treatment as you can see there there was
25:20
disease in quite a lot of areas we
25:25
removed peritoneal linings on the left
25:28
and the right and the immense him which
25:30
was that fat apron we removed her spleen
25:33
and she had an okay suspect me
25:36
we removed the linings of both of her
25:39
diaphragms on the left and the right you
25:41
remove the linings in her pelvis she had
25:45
a total hysterectomy a removal of her
25:49
ovaries and we did a remove her appendix
25:55
and she had a bladder repair as well and
25:59
there was a slight tear there and then
26:01
she had the Hawking therapy wash for an
26:04
hour afterwards and she had when she
26:07
came out the operation she had full
26:09
abdominal drains the right chest drain
26:12
another drain she was in the operation
26:15
room for about seven and a half hours
26:17
and with a minimal blood loss she
26:21
recovered really well after the
26:23
operation and after three weeks she was
26:25
discharged to her local team for
26:28
monitoring regularly and we recommend
26:31
Daniel scans so that was a really good
26:35
outcome for that patient
26:37
and referred to the National MDT where
26:40
we looked and she was suitable for the
26:43
full surgery and her outcome was with
26:47
successful after the operation simply
26:53
have a look into the future and what's
26:55
what's ahead of us well we we want to
26:58
continue our MD T and we will continue
27:01
that developing it looking at the
27:04
patients that have been referred over
27:06
the time and how they are doing what
27:09
treatments they received to get an idea
27:12
on on how these patients are being
27:14
treated and which ones are being treated
27:16
in which part of that spectrum in the
27:19
lower grade and the high grade we aim to
27:23
go back to NHS England with our data and
27:27
data that's been published worldwide
27:28
about the CRS and HIPEC surgery and ask
27:33
for them to Commission the surgery we're
27:36
looking at offering a prehabilitation
27:39
service for the surgical patients so
27:42
helping them to get fit and being best
27:47
shape as possible for recovery
27:50
afterwards we are looking at the
27:53
clinical trials that are available with
27:56
the systemic treatments that that can be
27:59
given for these patients and
28:00
immunotherapy is something that's at the
28:03
forefront at the moment we are looking
28:06
at something called PI Peck which is the
28:09
which is a pressurized chemotherapy
28:12
that's done at laparoscopy and that's
28:15
always a little sprayed into the
28:16
abdominal cavity and that's something
28:18
that we're looking at at the moment and
28:20
I'm watching the data worldwide and
28:23
thinking about whether we can offer
28:25
something in a clinical trial setting we
28:30
need to develop more information for
28:32
patients and leaflets and online
28:35
information and I think one of the big
28:39
things that these these patients and
28:41
their families that are asking for is is
28:43
support for one another and we are
28:47
looking at ways at doing virtual support
28:49
groups
28:50
and an events that we can do and to help
28:53
them talk to each other and share their
28:56
stories so in summary we have a look at
29:02
what we've just spoken about Paris
29:03
anomalies the MU is extremely rare and
29:06
it has links with us best exposure and
29:10
the chemotherapy is a good treatment
29:12
option which does gives limited benefits
29:15
is the palliative treatment and from
29:18
what we've seen the work that we're
29:20
doing we can achieve some good surgical
29:23
outcomes
29:24
for those patients that have been
29:26
carefully selected by the MDT thank you
29:32
a really helpful insight into personal
29:36
mesothelioma I think what you said about
29:39
just providing the support it's all the
29:43
patients but also pre and post operation
29:45
I think that will be really reassuring
29:47
some of the patients listening to your
29:51
presentation and it's also just kind of
29:55
dawned on me about the the remotes MDT's
29:58
that you you and the team have because
30:01
obviously I'm assuming those nd T's go
30:03
ahead because of geography or have done
30:05
in the past because you've got
30:06
specialists from all over the country
30:08
you've got treating patients not
30:12
necessarily in your local area and I
30:15
think we've shown haven't we that those
30:17
support group meetings as well can go
30:19
ahead remotely so I think that's you
30:21
know it's a really positive step that
30:23
you know you can hopefully start to
30:25
offer that remote support group as well
30:27
yes absolutely so I think we're going to
30:31
start our first virtual support group on
30:34
the 3rd of July which is the action miss
30:37
video today this is being done virtually
30:40
and hosted by the UK news Alliance and
30:44
I'm going to run a similar and seem cool
30:48
in the morning and for patients or their
30:51
families if they want to dial in and we
30:54
can have a chance with other people
30:57
around the UK and then that will launch
30:59
into the events that's being held by the
31:03
Alliance
31:04
breanne so I've got one question just
31:08
about the statistics that you mentioned
31:10
that the right at the beginning and of
31:12
course we see more males with
31:14
mesothelioma but what I was particularly
31:16
interested in really is with the females
31:19
the instance the peritoneal mesothelioma
31:21
is that little bit higher than for
31:23
plural and is there any reason behind
31:26
that do we know I think we could
31:29
probably have a look at those non
31:32
asbestos causes in a bit more detail and
31:36
perhaps those will mean that patients
31:41
with female patients perhaps that are
31:43
predisposed more the lower grade gliomas
31:48
the the multi sistex they seem to be
31:53
more prevalent in females as well and
31:55
there could be some hormonal link there
32:00
okay and our final question is from one
32:04
of the attendees so it's quite a
32:08
specific question that you may not be
32:10
able to answer exactly but he is at
32:13
Basin State Hospital and he wants to
32:15
know really if his CT scan is due to go
32:20
ahead in August obviously we're in a bit
32:23
of uncharted territory at the moment
32:24
what's the feeling on whether or not a
32:27
CT scan is happening as normal will it
32:29
be the stones you know what what do you
32:31
think might happen yet those services
32:35
are still running there are some slight
32:37
delays but I think we're seeing
32:40
particularly today services in the
32:43
retail industry all up and running today
32:46
and I think you I think we'll see a
32:49
quick escalation of services resuming
32:53
they're not not to be too panics about
32:56
an August scan and just to reassure
32:59
patients that we will get through their
33:02
routine scans and as as quick as we can
33:06
great it's really helpful Thank You
33:09
Samantha and thank you for sharing your
33:11
your time with us and taking the time
33:13
out today
33:14
many banks thanks for having me
English (auto-generated)
I'm Laura Maxon I'm a solicitor please
00:18
Turner welcome to you all and many
00:20
thanks for listening in today I'm joined
00:22
by Samantha Westbrook when we started
00:25
organizing our annual study day last
00:28
year I approached a number of speakers
00:30
including Samantha who kindly agreed to
00:32
talk about eight months ago now as our
00:35
mesothelioma and lung cancer study day I
00:37
don't think anybody expected that that
00:40
study day wouldn't be able to go ahead
00:41
face to face in our offices as planned
00:44
but nevertheless we've we've had to
00:46
adapt samantha has kindly agreed to do a
00:49
short webinar instead for those that
00:53
don't know Samantha Westbrook is a
00:54
peritoneal clinical nurse specialist at
00:57
the peritoneal malignancy Institute at
00:59
Basingstoke Hospital her post has been
01:02
funded by music the UK since I think
01:06
September 2018 it's a charity that's
01:09
fantastic it's nationwide and dedicated
01:12
to these at the Yeomen patients thank
01:14
you Sam for carrying on in these
01:16
unprecedented times I'll hand over to
01:18
you now Samantha if you'd like to tell
01:20
everybody what you're going to talk
01:22
about today oh hi good morning hi Laura
01:26
thank you for the kind introduction so
01:29
this one I'm going to talk to you about
01:30
peritoneal mesothelioma I'm going to
01:33
give you a little bit of an overview of
01:35
the peritoneal mesothelioma we're going
01:38
to look at the current landscape for
01:42
what that looks like in the UK for the
01:44
patients with peritoneal mesothelioma
01:46
and then I'm going to touch on what what
01:49
the future might hold and looking ahead
01:51
a little bit more so I'm going to share
01:53
my presentation with you so these are
01:55
the numbers that have been recently
01:57
published by the mesothelioma audit if
02:01
we look at the statistics here there are
02:04
about just over 7,000 patients in the UK
02:07
diagnosed with mesothelioma in the
02:11
two-year period this is 2016 2 18 of
02:15
those about 260 cases are peritoneal
02:19
mesothelioma and we can see here that
02:22
the mean median age is around 71 there
02:26
are more males and
02:28
females but there are slightly more
02:30
females than the males within the
02:32
parents Neil cases this audit really
02:37
showed the great work that's being done
02:40
by the charities by the other hospitals
02:43
with the National MDT's and all the
02:46
regional NZ teas and in particular for
02:49
us it showed that there was a doubling
02:52
of referrals to our national parents
02:54
know mesothelioma NDT from the previous
02:58
two years so that's a great achievement
03:00
for patients who are seeking that expert
03:03
advice and let's have a look at what
03:06
peritoneal mesothelioma is it's the
03:12
lining of the abdomen is the peritoneum
03:14
and what happens is the perineum
03:18
thickens when mesothelioma is present
03:21
and during that thickening it causes
03:25
fluid to collect now this fluid is
03:27
called ascites and when that happens the
03:30
abdomen swells the patient can be quite
03:32
uncomfortable with all that fluid there
03:34
there are two linings
03:36
there's the lining that's the visceral
03:38
lining which is next to the abdominal
03:40
organs and as the prize for lining that
03:43
lines the abdominal wall now personal
03:46
mesothelioma spreads outwards and around
03:49
it doesn't spread within it doesn't
03:52
infiltrate and it isn't him illogical
03:55
spread either it's quite unusual to see
03:58
the lymph glands affected by it and to
04:02
see any metastases out of the abdominal
04:04
cavity it's very rare and it's very
04:09
uncommon at the moment we don't know of
04:12
any cure and and there are some thoughts
04:16
on how music a glioma guess for the
04:19
peritoneum and one thought is that be
04:25
crystals are ingested and slowly over
04:29
time they migrate from the lumen of the
04:31
GI tract to the peritoneum and the
04:35
latency period is slightly shorter than
04:36
that of the pleural mesothelioma
04:39
and that's been documented about around
04:40
20 years there are some documented cases
04:46
as long as Vestas causes of personal
04:49
mesothelioma
04:50
some say that radiation causes it so
04:55
that's the directly irradiated tissues
04:58
there's issue instances of recurrence
05:03
peritonitis and so patients who have
05:06
relapsing diverticulitis or patients
05:09
with crohn's disease genetic
05:12
dispositions and also and a virus called
05:16
simian virus for T so if we look at
05:21
personal mesothelioma it's it's actually
05:24
classified into some different subtypes
05:26
we can put a couple into the low-grade
05:29
spectrum and we can put some into what
05:32
we call the higher grades and malignant
05:34
spectrum in the low-grade we see
05:37
something called multi system is the
05:38
video map and well-differentiated
05:40
Papillion is Aloma and in the high-grade
05:44
malignant spectrum we see epithelioid
05:47
and also chromatids and our biphasic and
05:51
a distribution and the sites of disease
05:54
can vary between each patient so the
05:59
multi cystic is an a low-grade
06:01
borderline malignant tumor it rarely
06:04
spreads outside the afternoon and it
06:06
does have high rates of recurrence
06:10
locally at the well differentiated
06:13
papillary is even rarer we don't see
06:16
many of those patients with with this
06:18
and it's slightly more frequent in the
06:22
personally in the plural
06:24
our most common is the epithelial age
06:27
and slightly more rare is the Stockholm
06:33
it's weight and the biphasic the
06:38
patients often have a delayed diagnosis
06:41
and this is due to dis symptoms being
06:44
fairly nonspecific symptoms rather
06:46
common symptoms and that you could put
06:49
down to perhaps more and
06:51
more common issues so we have things
06:56
like Domino paintings we have abdominal
06:58
swellings
07:00
change in bowel habits Teagan weight
07:03
loss perhaps the patient has had a
07:06
hernia and loss of appetite so quite
07:09
sort of nonspecific some red flags there
07:12
for cancer symptoms and patients often
07:15
go down different diagnostic pathways
07:17
and before they get to this diagnosis
07:20
and sadly the patients do present at a
07:23
at an advanced tumor stage so how do we
07:28
diagnose it well often patients would
07:31
have had a CT scan and for us when we're
07:34
looking at CT scan is extremely
07:37
important to look at the small bowel
07:39
using this CT and we want to an almost
07:42
estimate the degree of disease on the
07:46
small bowel and and and that can tell us
07:49
what and surgical options are available
07:53
pet and CT scans yet show us superiority
07:57
over the CT scans diagnostic laparoscopy
08:01
is are something that we use to look at
08:05
the disease distribution and estimate
08:08
the volume of disease and take biopsies
08:12
you can aspirate the ascites so that
08:15
fluid in the abdominal cavity we were
08:17
talking about earlier and that that that
08:19
can be helpful and but often it's non
08:21
diagnostic to give us a diagnosis of
08:24
peritoneal mesothelioma there are
08:32
options of treatment pathways and some
08:36
patients go onto a surveillance program
08:37
where we watch the disease they have
08:41
scans they will interview interval scans
08:44
over a period of time just watching the
08:47
disease some patients opt to have a
08:50
chemotherapy and and some perhaps would
08:53
consider having a surgery there are
08:56
clinical trial options available as well
08:59
and for patients who perhaps not
09:02
suitable for surgery or have had a
09:03
couple of
09:04
lines of chemotherapies so we just have
09:10
a quick look at the history NHS England
09:15
in 2015
09:17
made the decision not to routinely
09:19
commissioned surgery for peritoneal
09:22
mesothelioma the surgery that we do at
09:24
Basingstoke is called cytoreductive
09:27
surgery and hyperthermic chemotherapy we
09:33
shorten that Cirrus and HIPEC because
09:35
it's a bit of a mouthful to say all the
09:37
time and they the standard treatment is
09:41
is the chemotherapy now we have we have
09:47
a special interest in personal
09:49
mesothelioma amazing stick and music UK
09:52
in particular as well and in March 2016
09:57
the team decided to set up a national
10:00
personally glioma mzt meeting and
10:03
essentially they wanted to look at and
10:06
gain a consensus on what treatment
10:10
advice they can give and to look at
10:12
trends and how patients do over time
10:16
collecting their evidence and looking at
10:19
the data and the decision was made to
10:22
continue offering the surgery for
10:25
personal mesothelioma at our Hospital so
10:31
the MDT looks a bit like this it's a is
10:34
this a virtual MDT bit like what we're
10:37
all used to at the moment we have the
10:40
peritoneal malignancy surgeons at Good
10:43
Hope in Birmingham dial in and the
10:47
matter in Dublin dial in as well we have
10:51
expert pathologist who is well known in
10:56
in looking at personally see glioma we
10:59
have specialist nurse we have our
11:01
radiologist we have an oncologist and
11:03
our NDT coordinator collects all the
11:05
information for the meeting and we
11:08
review all the histology so we ask for
11:10
all the tissue blocks than the biopsies
11:14
to be sent to us for our pathologist her
11:17
have a look and to give a second opinion
11:19
all the images are reviewed we look at
11:22
the clinical information we might have
11:25
DVDs of laparoscopy that have been done
11:28
in the local hospitals or pictures for
11:30
us to look at I myself may have spoken
11:34
to the patient specialist nurse in their
11:37
local hospital or I might have actually
11:39
spoken to the patients or the families
11:40
themselves acting on their behalf and
11:42
knowing their wishes we recommend a
11:46
treatment pathway and that may be seeing
11:49
on an oncologist or it may be looking at
11:52
other any clinical trials available or
11:55
it may be looking at assessing them for
11:57
the suitability for the surgery it just
12:03
popped in a table here we recently
12:05
published a paper of our MD T and it is
12:09
it's interesting to have a look at the
12:11
number of cases that we looked at the
12:14
majority as we know the most common
12:16
epithelioid news Vienna followed by the
12:19
multi cystic and in the biphasic s--
12:22
after that and what we found from the
12:25
data was that patients who received the
12:29
Cirrus and HIPEC surgery showed a better
12:32
of one two and three year overall
12:34
survival and those were in patients that
12:37
were carefully selected through this MDT
12:39
process so what does the e surgery
12:44
involve well completely removing on this
12:47
tumor we call a complete site reduction
12:49
and its aims to remove all of that
12:51
macroscopic tumor but it can come with
12:55
its complications such as hemorrhages or
12:58
fish to lose perforations the wounds not
13:01
healing or abscesses and and at times we
13:05
can offer operations to remove a bulk of
13:09
disease perhaps if that's causing
13:11
problems for a patient discomfort pain
13:13
so we can help to remove disease that's
13:16
and causing symptoms there so in the
13:22
sugar bay
13:22
technique this is all the procedures
13:24
that are involved now not every patient
13:26
will have all of these procedures it's
13:29
specific to where their diseases so
13:32
right sides that the bowel can be
13:34
removed we would remove something called
13:37
the Ament 'm which is a fat apron but
13:39
over lays over the top of all of the
13:42
abdominal organs and we spleen may be
13:46
removed the gallbladder may be removed
13:49
patients may need a hysterectomy or
13:52
their ovaries removed we would strip the
13:56
peritoneum and strip the linings of the
13:58
diaphragm and perhaps the surface of the
14:03
liver and in some cases and there are
14:05
areas down in the rectum that needs to
14:07
be resected now the HIPEC is the heated
14:13
chemotherapy liquid and so this
14:16
addresses all the disease that we
14:17
perhaps can't see the macroscopic
14:19
disease we've removed all of the disease
14:21
that we can see with the crs and then
14:25
we're addressing the macroscopic disease
14:27
which is the chemotherapy wash now this
14:31
is isolated to the personal cavity it's
14:34
it's pumped in I'll show you the machine
14:37
on the next slide and it's left in the
14:40
cavity for about 60 minutes heated and
14:43
the organs are bathed and there's no
14:46
toxicity or side effects to the patient
14:49
and possible tiredness or nausea but you
14:54
would expect that after operation anyway
14:57
so this is what it looks like it's a
15:01
metal scaffolding there's built around
15:05
and then the tubes by the machine
15:08
pumping the hot chemotherapy wash in the
15:11
organs are bathed and then it's removed
15:16
for a patient who's undergoing this
15:19
surgery and this is sort of what their
15:22
initial journey might might look like on
15:26
the day of admission they'll come to us
15:28
two days before the actual operation
15:31
itself and all the usual paperwork's are
15:35
completed
15:36
now give them a liquid for a bell and to
15:39
clear out the boughs little pickle
15:41
accent she's a bowel prep and they will
15:44
be having clear fluids only and the day
15:49
before the operation is one of the
15:50
busier days actually so miss blue team
15:53
will come and see the patient and talk
15:56
to them we have dedicated stoma team who
16:00
come and see the patient so that's the
16:03
patient's who perhaps are having part of
16:05
their bowel removed and need to have a
16:07
bag on the outside on their tummy for
16:10
the stool to come out of that could be
16:12
either permanent or temporary the
16:16
anesthetist so the person who's putting
16:18
the patient to sleep and giving all the
16:20
sedation will come and see them we have
16:23
team of dieticians they will talk about
16:26
the artificial feeding that they'll be
16:30
getting for the first ten days and then
16:32
how they reintroduce food we have
16:35
physiotherapists and exercise
16:37
specialists and they will see the
16:39
patient really from the beginning and
16:41
out of the surgery and to get them up
16:44
and moving we offer them a visit to the
16:47
intensive care unit where they will stay
16:50
the first 24 hours minimum are to their
16:53
operation and the nurse myself I'll I'll
16:57
see the patient as well and we we talk
16:59
through all the ins and outs and what
17:00
what it might look like after the
17:02
operation and all those drains and the
17:04
drips that they that they will have and
17:07
on the day of the operation so they
17:09
don't have anything else to eat and
17:11
drink from midnight the night before and
17:13
they get woken up about 6 o'clock and
17:16
start getting getting ready a relative's
17:19
welcome to come and take them to the
17:21
operating theatre and the relatives will
17:25
receive two phone calls from the surgeon
17:27
during the day one usually just after
17:30
lunch and then one at the end these
17:34
patients do have complex care needs
17:36
after this operation often they would
17:39
have chest rings if they've had those
17:41
diaphragms stripped as I had mentioned
17:43
earlier they have multiple abdominal
17:46
drains to drain out any fluid
17:48
collections
17:50
they'd have to learn about this straight
17:51
macare if indeed they have a steamer all
17:54
patients do pain relief is one of our
17:57
big focuses so we really didn't want the
17:59
patients be any in any pain they'll have
18:02
an epidural in place and a button that
18:06
they can press to deliver extra
18:08
painkillers if they need it they are
18:12
ultimately artificially fed for around
18:14
ten days and like I said we we get the
18:18
patients up and moving very early on
18:21
sometimes patients will have the
18:23
chemotherapy wash after the operation as
18:27
well and that's what we shortened to
18:29
something called epic it's not always
18:32
done but it can be inserted through one
18:35
of those drains and left in under 24
18:38
hours and drained out the next day
18:41
now for a lot of patients this is an
18:45
emotional time and we recognize that and
18:48
so we do offer psychological support we
18:52
have a psychologist team for our
18:56
patients and they're screened before for
18:59
any anxiety and depression so that we're
19:02
able to support them the best we can
19:04
during this process and there are
19:07
various ways for us to get to know our
19:10
patients and this is something called
19:12
feeling out of Wankel this is me and we
19:15
can learn a little bit more about the
19:16
patient before they come and stay with
19:18
us and we offer inpatient Diaries as
19:21
well so there are a lot of worries and
19:27
concerns for these patients and I think
19:32
at the top of the list but for many and
19:34
which is an unsurprising is the
19:38
prognosis and what does this mean and
19:40
can we remove all of their tumor have we
19:44
got it all out how much longer will they
19:47
live for and so we have to support those
19:50
patients and try and answer those
19:52
questions as best we can the stoma can
19:55
be something that nobody particularly
19:58
wants and so we offer some counselling
20:00
for that the scar isn't
20:03
and see from the picture is a is a big
20:05
scar and for a lot of people that's
20:07
quite unsightly and it can take some
20:10
time to look at their belly button gets
20:12
removed during that process as well
20:13
which is quite unusual too when you look
20:16
down and see there's no belly button
20:19
so the scar can be a focus for a lot of
20:22
patients they're with us for about three
20:24
weeks and then afterwards when they go
20:27
home we offer a follow-up care so we do
20:31
telephone calls at certain points to
20:34
check that the patients are recovering
20:36
well at home and eleazar their local
20:39
teams so my role probably this bliss
20:46
isn't isn't exhaustive I support the
20:50
patients often remotely not only those
20:53
that are having this surgery but those
20:56
are going through all different
20:59
treatments in the UK I would signpost
21:03
them to various teams or various
21:07
services help them with any symptoms
21:12
that they are struggling with seeing if
21:14
there are all ways that we can help to
21:16
manage those speaking with their
21:18
specialist teams and their local
21:20
hospitals and specialist nurses and
21:26
often it can be talking about the
21:27
disease itself as we said that it's a
21:31
very rare disease and they find that
21:36
they want to talk to the people who have
21:39
experiencing in this service development
21:44
so we look at how we can improve our
21:47
treatments that were offering how can we
21:51
get it known what we're doing amazing
21:54
stake so I just thought I'd run through
21:59
a quick case study with you here just to
22:01
sort of set a bit more of a picture of
22:04
them perhaps what it might look like for
22:07
a patient
22:09
this referral came in last summer a
22:12
young female and with fit and well and
22:15
no medical history and she had they used
22:18
nonspecific symptoms that we spoke about
22:21
and was bit to handle something called
22:25
irritable bowel syndrome but these
22:28
didn't resolve and so she was referred
22:32
into the hospital and she had a
22:35
laparoscopy though this was her and
22:37
something to explore what might be going
22:40
on and inside the pelvic area looked
22:43
abnormal and so there was a biopsy that
22:45
was taken and this unfortunately came
22:49
back inconclusive and so no diagnosis
22:53
could be given so she went through a
22:55
second biopsy and that was reported as
22:59
the well differentiated papillary Parana
23:03
mesothelioma and that was the one that
23:06
we spoke about us it's in the low-grade
23:09
spectrum and she was informed by her
23:12
local team that this was something that
23:14
was low-grade and indolent and was
23:20
informed that her treatment options
23:22
could could bury and it could be either
23:24
the watch and wait or pass there might
23:26
be some chemotherapy or or an operation
23:28
might be needed so her local team
23:31
referred us referred her to us at our
23:34
national MDT and we had a look at that
23:36
in August and our pathologists had a
23:39
look and subtype t as epithelioid say
23:43
that moved it over into the malignant
23:46
spectrum and we do a particular test
23:52
calling ki-67 which is is slightly a
23:55
prognostic indicator and hers was around
23:58
20% around 9% is is that normal see
24:03
moving up higher is likely more
24:05
aggressive we had a look at her scans
24:09
which sewed quite extensive disease in
24:12
the in the lower part of in the pelvis
24:14
and their personal linings and also on
24:17
the diaphragm linings and we we
24:22
suggested that she'd
24:23
should consider some fertility options
24:27
and we had a look at the DVD from the
24:30
laparoscopy that was done in her local
24:33
Astra and it was quite difficult for us
24:34
to have a look on us to see the small
24:36
bowel and see if there was any disease
24:37
there so we decided we'd offer her our
24:42
patients appointment and we would do a
24:44
laparoscopy here at phasing snake and to
24:47
assess the disease so we did that in
24:50
October and it was decided that her
24:54
disease was operable and we'd be able to
24:56
achieve that full sight reduction and
25:00
that no bowel resections would be needed
25:02
and she'd in the meantime seen her
25:06
fertility team and her successful egg
25:09
collection so in November she had her
25:14
operation she had the CRS and HIPEC
25:17
treatment as you can see there there was
25:20
disease in quite a lot of areas we
25:25
removed peritoneal linings on the left
25:28
and the right and the immense him which
25:30
was that fat apron we removed her spleen
25:33
and she had an okay suspect me
25:36
we removed the linings of both of her
25:39
diaphragms on the left and the right you
25:41
remove the linings in her pelvis she had
25:45
a total hysterectomy a removal of her
25:49
ovaries and we did a remove her appendix
25:55
and she had a bladder repair as well and
25:59
there was a slight tear there and then
26:01
she had the Hawking therapy wash for an
26:04
hour afterwards and she had when she
26:07
came out the operation she had full
26:09
abdominal drains the right chest drain
26:12
another drain she was in the operation
26:15
room for about seven and a half hours
26:17
and with a minimal blood loss she
26:21
recovered really well after the
26:23
operation and after three weeks she was
26:25
discharged to her local team for
26:28
monitoring regularly and we recommend
26:31
Daniel scans so that was a really good
26:35
outcome for that patient
26:37
and referred to the National MDT where
26:40
we looked and she was suitable for the
26:43
full surgery and her outcome was with
26:47
successful after the operation simply
26:53
have a look into the future and what's
26:55
what's ahead of us well we we want to
26:58
continue our MD T and we will continue
27:01
that developing it looking at the
27:04
patients that have been referred over
27:06
the time and how they are doing what
27:09
treatments they received to get an idea
27:12
on on how these patients are being
27:14
treated and which ones are being treated
27:16
in which part of that spectrum in the
27:19
lower grade and the high grade we aim to
27:23
go back to NHS England with our data and
27:27
data that's been published worldwide
27:28
about the CRS and HIPEC surgery and ask
27:33
for them to Commission the surgery we're
27:36
looking at offering a prehabilitation
27:39
service for the surgical patients so
27:42
helping them to get fit and being best
27:47
shape as possible for recovery
27:50
afterwards we are looking at the
27:53
clinical trials that are available with
27:56
the systemic treatments that that can be
27:59
given for these patients and
28:00
immunotherapy is something that's at the
28:03
forefront at the moment we are looking
28:06
at something called PI Peck which is the
28:09
which is a pressurized chemotherapy
28:12
that's done at laparoscopy and that's
28:15
always a little sprayed into the
28:16
abdominal cavity and that's something
28:18
that we're looking at at the moment and
28:20
I'm watching the data worldwide and
28:23
thinking about whether we can offer
28:25
something in a clinical trial setting we
28:30
need to develop more information for
28:32
patients and leaflets and online
28:35
information and I think one of the big
28:39
things that these these patients and
28:41
their families that are asking for is is
28:43
support for one another and we are
28:47
looking at ways at doing virtual support
28:49
groups
28:50
and an events that we can do and to help
28:53
them talk to each other and share their
28:56
stories so in summary we have a look at
29:02
what we've just spoken about Paris
29:03
anomalies the MU is extremely rare and
29:06
it has links with us best exposure and
29:10
the chemotherapy is a good treatment
29:12
option which does gives limited benefits
29:15
is the palliative treatment and from
29:18
what we've seen the work that we're
29:20
doing we can achieve some good surgical
29:23
outcomes
29:24
for those patients that have been
29:26
carefully selected by the MDT thank you
29:32
a really helpful insight into personal
29:36
mesothelioma I think what you said about
29:39
just providing the support it's all the
29:43
patients but also pre and post operation
29:45
I think that will be really reassuring
29:47
some of the patients listening to your
29:51
presentation and it's also just kind of
29:55
dawned on me about the the remotes MDT's
29:58
that you you and the team have because
30:01
obviously I'm assuming those nd T's go
30:03
ahead because of geography or have done
30:05
in the past because you've got
30:06
specialists from all over the country
30:08
you've got treating patients not
30:12
necessarily in your local area and I
30:15
think we've shown haven't we that those
30:17
support group meetings as well can go
30:19
ahead remotely so I think that's you
30:21
know it's a really positive step that
30:23
you know you can hopefully start to
30:25
offer that remote support group as well
30:27
yes absolutely so I think we're going to
30:31
start our first virtual support group on
30:34
the 3rd of July which is the action miss
30:37
video today this is being done virtually
30:40
and hosted by the UK news Alliance and
30:44
I'm going to run a similar and seem cool
30:48
in the morning and for patients or their
30:51
families if they want to dial in and we
30:54
can have a chance with other people
30:57
around the UK and then that will launch
30:59
into the events that's being held by the
31:03
Alliance
31:04
breanne so I've got one question just
31:08
about the statistics that you mentioned
31:10
that the right at the beginning and of
31:12
course we see more males with
31:14
mesothelioma but what I was particularly
31:16
interested in really is with the females
31:19
the instance the peritoneal mesothelioma
31:21
is that little bit higher than for
31:23
plural and is there any reason behind
31:26
that do we know I think we could
31:29
probably have a look at those non
31:32
asbestos causes in a bit more detail and
31:36
perhaps those will mean that patients
31:41
with female patients perhaps that are
31:43
predisposed more the lower grade gliomas
31:48
the the multi sistex they seem to be
31:53
more prevalent in females as well and
31:55
there could be some hormonal link there
32:00
okay and our final question is from one
32:04
of the attendees so it's quite a
32:08
specific question that you may not be
32:10
able to answer exactly but he is at
32:13
Basin State Hospital and he wants to
32:15
know really if his CT scan is due to go
32:20
ahead in August obviously we're in a bit
32:23
of uncharted territory at the moment
32:24
what's the feeling on whether or not a
32:27
CT scan is happening as normal will it
32:29
be the stones you know what what do you think might happen yet those services are still running there are some slight delays but I think we're seeing particularly today services in the retail industry all up and running today and I think you I think we'll see a quick escalation of services resuming they're not to be too panics about an August scan and just to reassure patients that we will get through their routine scans and as as quick as we can great it's really helpful
Thank You Samantha and thank you for sharing your your time with us and taking the time out today
Many thanks for having me
