01. Mesothelioma Surgery Overview
What Is Mesothelioma Surgery?
Mesothelioma surgery is an umbrella term for procedures used to remove cancer cells. Doctors may perform surgeries for a number of reasons.
Doctors commonly treat mesothelioma with surgery plus other therapies. This method of combining therapies is called multimodal treatment. A multimodal treatment plan involving surgery is often the most effective way of extending patient survival.
Reasons a doctor may recommend mesothelioma surgery include:
- Diagnosing mesothelioma: Doctors may use several surgical interventions to diagnose mesothelioma. For example, doctors may perform a surgical biopsy to collect a tissue sample from a patient. The biopsy sample can then be used to confirm diagnosis and identify mesothelioma cell type.
- Extending patient survival: Surgery-based multimodal treatments often achieve the best life-extending results. Doctors may combine therapeutic surgery with chemotherapy, radiation or other types of treatment.
- Improving symptoms or quality of life: Doctors may use palliative surgical procedures to address symptoms of mesothelioma and improve quality of life. For example, patients may undergo surgery to prevent fluid buildup in the lungs.
Mesothelioma patients may have several surgical options available to them. Options vary based on several factors, including mesothelioma location and the goal of the surgery.
Goals of Surgery for Mesothelioma
Surgery goals affect the type of procedure a mesothelioma doctor may recommend. The goal of a mesothelioma surgical procedure may be:
- Diagnosis: Diagnostic surgeries seek to confirm that a person has mesothelioma. They may also provide information about the type of mesothelioma.
- Palliation: Palliative surgeries seek to manage mesothelioma symptoms and improve quality of life.
- Treatment: Therapeutic surgeries seek to treat mesothelioma to extend life expectancy.
A doctor can explain surgical options based on a patient’s needs and treatment goals. Surgery is often an important part of a patient’s overall treatment plan.
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02. Types of Mesothelioma Surgery
Mesothelioma Surgery Types
There are many types of surgery for mesothelioma. Some common surgeries include pleurectomy decortication (P/D) and extrapleural pneumonectomy (EPP). In general, mesothelioma surgery types can be categorized by their goal. The three main goals of surgery are diagnosis, therapeutic treatment and palliative treatment.
Diagnostic Surgery for Mesothelioma
Diagnostic surgery procedures help determine whether a person has mesothelioma. For mesothelioma patients, a biopsy is the only way to obtain a definitive diagnosis. During a biopsy, doctors collect tissue samples from a patient for analysis.
Types of diagnostic surgeries a mesothelioma patient may undergo include:
- Laparoscopy: A doctor makes a small incision in the abdomen and inserts a device called a laparoscope. This device can collect samples and also has a camera component. It is commonly used to diagnose peritoneal mesothelioma.
- Laparotomy: A doctor makes a large incision in the abdomen. This allows the doctor to directly collect samples and view tissue. These samples can be used to diagnose peritoneal mesothelioma.
- Mediastinoscopy: A doctor makes a small incision in the chest and inserts a device called a mediastinoscope. The device is similar to a laparoscope. It may be used to diagnose malignant pleural mesothelioma.
- Thoracoscopy: A doctor makes a small incision in the chest and inserts a device called a thoracoscope. The device is similar to a laparoscope. It is recommended for obtaining an adequate biopsy sample in pleural mesothelioma patients.
- Thoracotomy: A doctor makes a large incision in the chest. The procedure is similar to a laparotomy and may be used to collect samples to diagnose pleural mesothelioma.
Laparoscopies and other procedures involving small incisions usually require general anesthesia. These procedures are considered minimally invasive. However, putting the patient to sleep helps them avoid pain and discomfort. Laparotomies and other procedures involving large incisions are always done under general anesthesia.
Therapeutic Surgery for Mesothelioma
Therapeutic surgery is a type of procedure to treat mesothelioma. Surgeons perform this procedure to remove as much cancer as possible, with the goal of extending patient survival.
Doctors may combine surgery with other treatments like chemotherapy to help improve a mesothelioma prognosis. Surgery-based combination treatments are often the most successful in extending mesothelioma life expectancy.
What Is Curative Surgery?
Patients may hear the term “curative surgery” when discussing surgery options. Doctors perform curative surgery to remove all cancer tissue and cure the cancer entirely. There are currently no curative treatments for mesothelioma, surgical or otherwise. However, therapeutic treatments are available to help extend mesothelioma patients’ survival.
Therapeutic surgeries are often combined with other therapies as part of a multimodal treatment plan. In addition to surgery, mesothelioma patients may receive:
- Radiation therapy
Eligible patients may also receive experimental treatments through clinical trials. Researchers continue to seek the most effective treatment combinations for mesothelioma.
Common Therapeutic Surgeries by Mesothelioma Location
- Pleural mesothelioma: Pleurectomy decortication (P/D) and extrapleural pneumonectomy (EPP)
- Peritoneal mesothelioma: Cytoreduction surgery (CRS)
- Pericardial mesothelioma: Pericardiectomy
Palliative Surgery for Mesothelioma
Palliative surgery is a type of procedure to manage symptoms and improve quality of life. For example, many mesothelioma patients experience fluid buildup around the lungs, abdomen or heart. This may cause chest or abdominal pain, difficulty breathing or shortness of breath. In these cases, doctors may perform palliative surgery to drain excess fluid and relieve pressure in the chest or abdomen.
Palliative care is often associated with stage 3 or stage 4 cancer, but patients with any stage of mesothelioma may undergo palliative surgery. Doctors may recommend it at any point to help improve a patient’s quality of life.
Palliative Mesothelioma Surgeries by Mesothelioma Location
- Pleural mesothelioma: Pleurocentesis, pleurodesis and pleurectomy/decortication (P/D)
- Peritoneal mesothelioma: Paracentesis
- Pericardial mesothelioma: Pericardiocentesis and pericardiectomy
Resources for Mesothelioma Patients
03. Surgery for Pleural Mesothelioma
Pleural Mesothelioma Surgery Options
Surgery is a common procedure for pleural mesothelioma. The surgery may be aggressive, with the goal of extending life expectancy. It may also be less aggressive, with the goal of managing symptoms and improving quality of life.
Pleural mesothelioma develops in the lining around the lungs, known as the pleura. Common pleural mesothelioma surgeries include pleurectomy decortication (P/D) and extrapleural pneumonectomy (EPP).
Therapeutic Surgeries for Pleural Mesothelioma
Doctors conduct therapeutic surgeries for pleural mesothelioma with the goal of extending survival. Common therapeutic surgeries include P/D or EPP. The type of surgery they receive depends on several factors, including location of tumor masses and mesothelioma cell type.
Pleural mesothelioma specialists can determine the best surgical option for patients based on their individual cases.
A P/D is a two-part surgery to treat mesothelioma. During a pleurectomy, a mesothelioma surgeon removes the pleura (the lining around the lungs). If the cancer has spread to other tissues, this step may also include full or partial removal of the pericardium (lining around the heart) or diaphragm. A doctor then performs a decortication, removing any remaining tumors from the chest cavity.
P/D is considered a lung-sparing surgery because it leaves the lungs intact.
Patients may also receive P/D to help manage mesothelioma symptoms. Removal of the pleura can help prevent fluid buildup in the lungs.
Extrapleural Pneumonectomy (EPP)
An EPP is a highly aggressive surgery. During EPP, doctors remove a lung and the pleura, as well as all or portions of the diaphragm and lining around the heart. It is a more aggressive procedure than P/D. It may be an option for patients whose cancer has spread to the lung, pericardium or diaphragm. In general, EPP surgeries are less common than they used to be.
What Is It Like to Have an EPP Surgery?
Heather Von St. James was diagnosed with pleural mesothelioma in 2005. She had an initial prognosis of 15 months. She underwent an EPP, followed by chemotherapy and radiation. Today, she is a survivor of more than 17 years.
Palliative Surgeries for Pleural Mesothelioma
Pleural mesothelioma patients may undergo palliative surgery to address uncomfortable symptoms. Palliative surgery can help manage symptoms and improve quality of life. For example, mesothelioma patients may receive surgery to relieve pleural effusion.
Pleural effusion is a buildup of excess fluid in the lungs. It may cause difficulty breathing, coughing and chest pain. Surgical procedures like pleurocentesis can help remove fluid from the pleural space.
Pleurocentesis removes excess fluid surrounding the lungs. This procedure provides temporary relief of pleural effusion symptoms, like shortness of breath.
To perform a pleurocentesis, doctors insert a needle or tube into the pleural space to drain excess fluid. The procedure usually takes 10 – 15 minutes, and rarely lasts more than 30 minutes.
Patients may also hear this surgery referred to as thoracentesis.
Pleurodesis is a procedure to help treat and prevent fluid buildup in the lungs. It is considered a more long-term solution to pleural effusion than pleurocentesis. This is because it can help prevent the recurrence of fluid buildup in some patients.
Pleurodesis collapses the pleural space where fluid can build up. This can help relieve pleural effusion symptoms, like difficulty breathing.
Who Is Eligible for Pleural Mesothelioma Surgery?
Eligibility for pleural mesothelioma surgery depends on several factors. A mesothelioma doctor can determine a patient’s eligibility based on their individual case. Surgery-based combination therapy has shown the best results for treating pleural mesothelioma.
In general, a mesothelioma doctor may consider the following factors when evaluating surgery eligibility:
- Ability to engage in everyday activity (also known as performance status)
- Cancer cell type
- How far the cancer has spread (also known as metastasis)
- Other conditions the patient has (also known as comorbidities)
- Patient preferences
- Stage of disease
How doctors weigh these factors varies based on the surgery being considered. For example, the eligibility requirements for P/D differ from the eligibility requirements for EPP.
Currently, cancer cell type can influence surgery eligibility. Doctors may consider patients with epithelioid cell mesothelioma good candidates for surgery. Patients with sarcomatoid cell type mesothelioma are generally considered less favorable candidates for surgery.
The cell type eligibility criteria for pleural mesothelioma surgery could change in the future. Some experts want to reconsider cell type criteria in light of advances in immunotherapy treatment. They believe it is possible patients who are not eligible for surgery could become eligible after immunotherapy.
04. Surgery for Peritoneal Mesothelioma
Peritoneal Mesothelioma Surgery Options
Peritoneal mesothelioma occurs in the lining around the abdomen, also called the peritoneum. Surgery may help extend patient survival or improve quality of life. Eligible patients may undergo cytoreductive surgery (CRS), often with a chemotherapy component like HIPEC.
HIPEC stands for hyperthermic intraperitoneal chemotherapy. It is a heated chemotherapy wash applied to the abdomen. Surgery and HIPEC have demonstrated effectiveness in treating peritoneal mesothelioma.
Therapeutic Surgeries for Peritoneal Mesothelioma
Peritoneal mesothelioma patients may qualify for therapeutic surgery. For example, doctors may recommend a peritonectomy or CRS. These surgeries are often combined with other types of treatment to achieve the best results.
Peritoneal mesothelioma specialists can determine the best treatment options for patients. Factors they may consider to evaluate eligibility include cancer stage and cell type.
Cytoreductive Surgery (CRS)
Doctors perform CRS to remove visible tumor tissue from the abdomen. It may involve the partial or whole removal of the abdominal lining. It is often combined with HIPEC immediately following surgery. The goal of this combination is to get rid of as much cancer as possible. The surgery removes large, visible tumor masses. HIPEC attacks smaller masses and cells left behind after surgery.
CRS plus HIPEC is a standard treatment for peritoneal mesothelioma. Other chemotherapy treatments that may be used with CRS, either with or without HIPEC, include:
- Early postoperative intraperitoneal chemotherapy (EPIC)
- Hyperthermic intrathoracic chemotherapy (HITHOC)
- Normothermic intraperitoneal chemotherapy (NIPEC)
- Pressurized intraperitoneal aerosol chemotherapy (PIPAC)
Patients may also hear CRS referred to as debulking or peritonectomy.
Palliative Surgery for Peritoneal Mesothelioma
Peritoneal mesothelioma patients may undergo palliative surgery to help improve quality of life. Peritoneal mesothelioma can cause abdominal swelling and pain, vomiting and loss of appetite. These may be caused by peritoneal effusion, a condition where excess fluid builds up in the abdominal cavity. Palliative surgery can help manage discomfort caused by mesothelioma symptoms like peritoneal effusion.
Paracentesis is a procedure to remove excess fluid in the abdomen. The procedure is minimally invasive and can relieve abdominal pain caused by fluid buildup. It usually takes about 30 minutes to complete.
Paracentesis may need to be repeated if fluid buildup recurs.
Who Is Eligible for Peritoneal Mesothelioma Surgery?
Eligibility for peritoneal mesothelioma surgery depends on several factors. Experienced doctors can determine eligibility based on a patient’s individual case. In general, mesothelioma doctors may consider the following when evaluating surgery eligibility:
- Cancer cell type
- How far the cancer has spread (also known as metastasis)
- Other conditions the patient has (also known as comorbidities)
- Stage of disease
Doctors weigh these factors based on the type of surgery being considered. For example, overall health is an important factor in eligibility for CRS plus HIPEC.
Some patients who are initially ineligible for surgery can become eligible with the right treatments. For example, PIPAC has helped improve symptoms enough in some ineligible patients that they became eligible for surgery.
05. Surgery for Rare Mesothelioma
Pericardial and Testicular Mesothelioma Surgery Options
Pericardial and testicular mesothelioma are both rare types of mesothelioma. As such, surgery options for pericardial and testicular mesothelioma are not well documented. Experienced doctors can determine surgery eligibility based on a patient’s individual case.
Therapeutic Surgery for Pericardial Mesothelioma
Therapeutic surgery for pericardial mesothelioma is not well documented because the disease is quite rare. It accounts for 1% or less of mesothelioma cases. It occurs in the lining around the heart, called the pericardium.
Surgery-based combination therapy is generally the best method of treating mesothelioma. Pericardial patients may receive chemotherapy or radiation along with surgery. This multimodal approach may help prolong mesothelioma life expectancy.
Pericardial mesothelioma patients may undergo a pericardiectomy to remove all or part of the lining around the heart. This procedure can be therapeutic or palliative. It may relieve symptoms associated with stiffening of the pericardium, including chest pain.
Palliative Surgery for Pericardial Mesothelioma
Because pericardial mesothelioma is difficult to diagnose early, palliative surgery is common for this type of mesothelioma. Palliative surgery may alleviate uncomfortable symptoms and improve patient quality of life.
Pericardiocentesis is a procedure to relieve pericardial effusion, which is a buildup of fluid around the heart. This condition may cause chest pain, arrhythmia and changes in blood pressure.
Who Is Eligible for Pericardial Mesothelioma Surgery?
Pericardial mesothelioma is very rare. There are no official guidelines for treatment. Therefore, it is not clear what the eligibility requirements are for surgery. A doctor can help determine eligibility based on an individual patient’s case.
Surgery for Testicular Mesothelioma
Surgery for testicular mesothelioma is not well documented because it is one of the rarest forms of asbestos cancer. It accounts for less than 1% of all mesotheliomas. It develops in the lining around the testes.
Specific treatment guidelines for testicular mesothelioma have not yet been developed. Doctors may recommend a radical orchiectomy to treat this disease. A radical orchiectomy removes a testicle.
Some evidence shows that surgery for testicular mesothelioma is more effective at extending survival than surgery for other types of mesothelioma.
Who Is Eligible for Testicular Mesothelioma Surgery?
It is not clear what the eligibility requirements for surgery are because official treatment guidelines are not yet established. An experienced doctor can help determine a patient’s eligibility based on their individual case.
06. Surgery Preparation
Preparing for Mesothelioma Surgery
Mesothelioma patients can take steps to prepare for surgery. These steps help ensure the patient is able to undergo and recover from their procedure. A patient’s oncology team can tell them how to prepare for their specific surgery.
In general, a patient may be asked to prepare for surgery by:
- Following instructions about eating and drinking before surgery: In some cases, patients may need to stop eating or drinking in the immediate lead-up to surgery. This helps cut down on risks associated with vomiting. In general, doctors may ask patients to abstain from eating for up to 8 hours before surgery and drinking for up to 2 hours before surgery.
- Getting tests to ensure eligibility for surgery: A patient’s oncology team may require certain tests or exams before surgery, like blood tests or x-rays. It is important that patients get these tests to help ensure they are healthy enough to undergo surgery.
- Optimizing nutrition: Surgery increases the body’s need for good nutrition. Weak or underweight patients may need to eat a high-calorie, high-protein diet before surgery. A dietitian can help patients optimize their diet both before and after surgery.
Mesothelioma patients can ask their oncology team any questions they may have about preparing for their surgery. Surgery preparation instructions vary based on the procedure.
07. Surgery and Survival
Mesothelioma Surgery May Extend Survival
Surgery-based combination therapy is the gold standard for eligible mesothelioma patients. Multimodal approaches have achieved the best results in extending patient survival. Doctors may combine surgery with chemotherapy, radiation or other therapies to achieve the best results.
In one study, pleural mesothelioma patients received chemotherapy followed by surgery. Some patients also received additional chemotherapy. The median overall survival for patients was 57 months, with a 3-year survival rate of 65%. In contrast, a separate study measured survival in pleural mesothelioma patients who received chemotherapy alone. Their 3-year survival rate was much lower, at 15%.
For peritoneal mesothelioma, one study looked at results for patients who underwent CRS combined with HIPEC. It reported a median overall survival of 67 months, with a 3-year survival rate of 40%. Other studies have reported high survival rates when combining CRS and HIPEC with other chemotherapy treatments, including:
- CRS plus HIPEC and EPIC: 5-year survival rate of 52%
- CRS plus HIPEC, EPIC and NIPEC: 5-year survival rate of 75%
Surgery-based multimodal therapies have also been shown to improve survival for pericardial and testicular mesothelioma patients.
08. Side Effects of Surgery
Potential Side Effects of Mesothelioma Surgery
Mesothelioma patients may experience different surgery side effects based on several factors. Surgery type, cancer location, cancer cell type, disease stage and patient health can all impact side effects.
Side effects may also vary if surgery is combined with other treatments, like chemotherapy and radiation. Patients can discuss potential side effects with a member of their oncology team. After surgery, patients can receive follow-up care through their mesothelioma cancer center or oncology team to help manage side effects.
Common Mesothelioma Surgery Side Effects
- Anesthesia complications
- Blood clots
- Damage to nearby tissues
- Digestive problems
- Heart complications
- Respiratory problems
Speak With a Mesothelioma Survivor
- 17-year survivor
- A successful surgery
- Coping strategies
09. Surgery Recovery Process
What Is the Recovery Process for Mesothelioma Surgery?
The mesothelioma surgery recovery process varies depending on the type of surgery. Patients who undergo more aggressive surgeries may spend several weeks in the hospital. These patients often need extra recovery time at home as well. Other, less invasive surgeries may have quicker recovery times. Other factors, like patient health and surgery side effects, may also affect recovery time.
General recovery processes for each type of surgery may be as follows:
- Diagnostic surgery: Recovery from diagnostic procedures is relatively quick. Biopsies and other diagnostic surgeries are minimally invasive procedures. For example, patients who undergo a laparoscopy usually recover within a week. Doctors may recommend patients avoid strenuous activity and keep the incision site clean.
- Palliative surgery: Palliative surgeries may be less invasive than therapeutic options. Patients may need days or more than a week to recover. For example, patients who undergo pleurodesis, which collapses the pleural space, may spend 5 – 7 days in the hospital to recover. Patients who undergo a paracentesis to drain excess fluid may only need a day to recover.
- Therapeutic surgery: Therapeutic surgeries are often the most invasive and aggressive. Recovery from a serious procedure may take many weeks to months. For example, a patient may need 8 – 10 weeks to recover from an EPP. Recovery may take longer, depending on various factors.
Patients can talk to their doctor to understand what the recovery process may be like for their specific surgery.
10. Common Questions
Common Questions About Surgeries for Mesothelioma
Can mesothelioma be removed with surgery?
- Mesothelioma surgery can help patients by removing tumor tissue. Notable surgeries to remove mesothelioma tumors include pleurectomy/decortication (P/D) and cytoreductive surgery (CRS). Patients who qualify for surgery usually undergo other treatment to help kill cancer cells left behind after surgery. For example, cytoreductive surgery is often followed by chemotherapy.
How long does mesothelioma surgery take?
- A P/D plus chemotherapy typically lasts 6 – 7 hours but may take longer. CRS plus chemotherapy lasts 6 – 9 hours but may take longer. Mesothelioma surgery length may depend on which type of procedure a patient undergoes. For example, therapeutic surgeries aimed at removing as much cancer tissue as possible last much longer than most diagnostic surgeries.
Can mesothelioma be cured with surgery?
- Mesothelioma cannot be cured with surgery alone. But many long-term survivors received surgery-based combination treatments. Mesothelioma researchers and doctors work to make these treatments more effective. This includes work aimed at achieving a functional cure.
How successful is surgery for mesothelioma?
- Surgery-based combination treatments are the most successful in extending mesothelioma life expectancy for eligible patients. Results may vary based on the type of mesothelioma, patient health, stage of disease and other factors. In one study, pleural mesothelioma patients received multimodal treatment that included surgery. The majority of patients survived more than 3 years. Peritoneal mesothelioma patients who receive multimodal treatment that includes surgery generally survive 5 years or longer.