Surgery is a common treatment option for mesothelioma that can be used during the diagnostic process to retrieve a biopsy sample, to remove as much of the cancer as possible or palliatively to reduce patient symptoms. Surgery is often part of a multimodal plan, used in combination with chemotherapy and/or radiation therapy.
There are many types of mesothelioma surgeries, differing based on purpose and mesothelioma location. Aggressive surgeries are most common for early stage patients with minimal spreading and often aren’t an option for late-stage patients, older patients or those with poor overall health.
How Surgery Treats Mesothelioma
Surgery may be a part of primary treatment for mesothelioma, but can also be used prior to treatment, during diagnosis. Early detection is the best way to improve patient prognosis, and surgical biopsies can help physicians gather a tissue or fluid sample for analysis to confirm malignancy, cancer type, cell type and contribute to staging.
Mesothelioma surgeries aim to remove as much of the cancer as possible, including mesothelioma tumors and affected organs or tissues, if possible. This option is most common for stage 1 or stage 2 mesothelioma patients when mesothelioma tumors are still localized.
During stage 3 and stage 4, the cancer has spread to distant lymph nodes or organs, and patients may also be in poor overall health, eliminating surgery as a viable option. However, surgery may be used palliatively for those with any stage of the disease to relieve symptoms and improve quality of life. Common symptoms of malignant mesothelioma include chest pain or abdominal pain, difficulty breathing and shortness of breath caused by fluid buildup (peritoneal effusion and pleural effusion). Palliative surgeries are common to reduce tumor size and drain excess fluid, alleviating pressure and offering symptomatic relief.
Types of Mesothelioma Surgery
Surgeries differ based on whether they are for diagnostic, cytoreductive or palliative purposes, as well as their location, which is determined by the type of mesothelioma. Diagnostic surgeries are used to collect a sample to accurately diagnose the disease, while cytoreductive surgeries are treatments that involve the removal of as much of the cancer as possible. Palliative surgeries are designed to alleviate symptoms for the patient.
Diagnostic Mesothelioma Surgeries
A biopsy is the only definitive way to diagnose mesothelioma, and can be performed by taking a fluid or a tissue sample. Surgical biopsies can be minimally invasive, though some are considered open surgical procedures because the impacted tissue or fluid may be more difficult to reach or to ensure removal of a large enough sample for proper analysis.
- Thoracoscopy: A minimally invasive biopsy used to diagnose pleural mesothelioma. Small incisions are made between the chest and ribs to remove a tissue sample from the pleural or thoracic cavity.
- Laparoscopy: A minimally invasive biopsy most commonly used to diagnose peritoneal mesothelioma. Incisions are made in the stomach and abdomen, while gas inflates the peritoneal cavity. A scope is then used to locate and remove a tissue sample.
- Mediastinoscopy: A minimally invasive biopsy used to diagnose pericardial mesothelioma or when metastasis through the chest is suspected. A mediastinoscope is inserted below the neck to locate and remove a tissue sample for analysis.
- Thoracotomy: An open surgical procedure used to diagnose pleural and pericardial mesothelioma, where an incision is made in the chest wall to collect a tissue sample from around the heart, lungs or other areas where tumors are thought to be growing.
Cytoreductive Mesothelioma Surgeries
Cytoreductive mesothelioma surgeries are typically only used for stage 1 or stage 2 patients, when the disease has not metastasized to distant lymph nodes or organs, with the goal of removing as much of the cancer as possible. According to recent studies, less than one in five patients with malignant pleural mesothelioma that has spread are able to undergo surgical resection.
Researchers continue to seek the most effective modes of surgical treatment for mesothelioma, with studies finding improved survival rates when combined with radiation therapy and chemotherapy as part of a multimodal treatment plan. Cytoreductive surgeries are often followed by radiation therapy or chemotherapy to kill remaining cancer cells and prevent recurrence. For example, studies have found that pneumonectomy followed by radiation can prevent tumor recurrence in the chest in 80 – 85% of patients.
Cytoreductive surgeries are different based on mesothelioma type, targeting the chest, abdomen or testis. Common cytoreductive surgeries by type include:
- Pleural mesothelioma: Pleurectomy and extrapleural pneumonectomy
- Peritoneal mesothelioma: Peritonectomy and cytoreduction/debulking
- Pericardial mesothelioma: Pericardiectomy
- Testicular mesothelioma: Inguinal orchiectomy and lymphadenectomy
A mesothelioma pleurectomy is a surgical procedure that removes the mesothelial lining of the lung and the chest cavity, and may involve removal of the pericardium (lining of the heart) and peritoneum (lining of the abdominal cavity). In the case of a pleurectomy/decortication, surgeons remove as much of the malignant tissue around the lung as possible. In addition to treating mesothelioma, this surgery may also be used to remove excess fluid from the lungs.
An extrapleural pneumonectomy (EPP) is an aggressive surgical procedure that removes one lung and tissues surrounding the lung, such as the linings of the heart and abdomen, as well as parts of or all of the diaphragm. Typically only patients in the earlier stages of their diagnosis and in good overall health can undergo the surgery due to the risks.
A peritonectomy is used to treat peritoneal mesothelioma by removing the lining of the abdomen. Studies have seen success in combining a peritonectomy with hyperthermic intraperitoneal chemotherapy (HIPEC) and extending life expectancies.
Peritoneal mesothelioma can easily spread to organs throughout the abdomen, in which case cytoreduction/debulking may be used. This surgical procedure removes as many visible tumors from the abdominal region as possible, and often is accompanied by a HIPEC wash to kill any remaining cancer cells and help prevent recurrence.
A pericardiectomy is used to treat pericardial mesothelioma by removing the pericardium, or lining of the heart. In most cases, the pericardium is replaced with surgical Gore-Tex, so the heart can continue to pump smoothly.
An inguinal orchiectomy is used to treat testicular mesothelioma by removing one or both testicles and the entirety of the spermatic cord. Oftentimes, the surgery is followed by chemotherapy or radiation therapy to kill any remaining cancer cells and to help prevent metastasis or recurrence.
Palliative Mesothelioma Surgeries
Mesothelioma surgeries may also be performed as palliative treatments. Palliative surgeries are most common for stage 3 or stage 4 patients when surgical resection is no longer an option and the goal is to reduce symptoms and improve quality of life. Palliative mesothelioma surgeries by type include:
- Pleural mesothelioma: Pleurocentesis and pleurodesis
- Peritoneal mesothelioma: Paracentesis
- Pericardial mesothelioma: Pericardiocentesis
- Testicular mesothelioma: Hydrocelectomy
A common symptom of malignant pleural mesothelioma is pleural effusion, when fluid builds up around the lungs causing an array of other symptoms, like difficulty breathing, coughing and chest pain. Pleurocentesis is a procedure that uses a needle to drain this fluid, improving the patient’s comfort. In some cases, a catheter may be left in the pleural cavity that can be drained as needed.
Similar to pleurocentesis, pleurodesis is a surgery for pleural mesothelioma used to address pleural effusion. A chemical substance such as talc is used to irritate and inflame the pleural membranes, causing them to expand and adhere together where pleural fluid would otherwise accumulate. This allows the lungs to fully expand, reducing pain and improving breathing.
Peritoneal effusion, or fluid buildup around the abdomen, is a common symptom of peritoneal mesothelioma that can then cause other symptoms, like abdominal swelling and pain, vomiting, loss of appetite and nausea. Paracentesis is a procedure that drains the excess fluid, helping to alleviate symptoms for the patient. In some cases, a catheter may be left in the peritoneal cavity that can be drained as needed.
Pericardial mesothelioma can cause pericardial effusion, or a buildup of fluid around the heart, leading to chest pain, arrhythmia and changes in blood pressure. Pericardiocentesis is a surgical procedure that drains the excess fluid from the pericardial space, helping reduce symptoms. In some cases, a catheter may be left in the pericardial cavity that can be drained as needed.
Testicular mesothelioma patients often have uncomfortable swelling of the scrotum. The hydrocele is a fluid-filled sac within the scrotum that causes swelling. Often performed during an orchiectomy, a hydrocelectomy removes the hydrocele to assist with a reduction in swelling and associated symptoms.
Side Effects of Mesothelioma Surgery
Side effects for mesothelioma patients undergoing surgery will vary based on surgery type, mesothelioma type and patient characteristics like overall health, age and other existing conditions. However, there are common surgery side effects that patients can discuss with their medical team prior to treatment to fully understand the benefits and risks.
- Anesthesia complications
- Bleeding and blood clots
- Heart complications
- Loss of appetite
- Low blood pressure
- Respiratory problems
Depending on the invasiveness of the surgery, patients may require recovery at the hospital to monitor for potential complications. There are often medications and other treatment options patients can pursue to alleviate and prevent symptoms of surgery. Researchers and thoracic surgeons continue to study the use of surgery in mesothelioma treatment, using clinical trials to measure its efficacy with other treatment options.
Author: Linda Molinari
Editor in Chief, Mesothelioma Cancer AllianceRead about Linda
Reviewer: Dr. James Stevenson
Medical Reviewer and Thoracic Medical OncologistRead about Dr. Stevenson
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Pai VB, Rammohan KS and Treasure T. Surgery for mesothelioma: the evidence base and a pragmatic approach to surgical treatment. Indian Journal of Thoracic and Cardiovascular Surgery. January 2018;34(1):65-71.