After a patient is diagnosed with mesothelioma, surgery is one of the standard forms of treatment used to remove tumors, providing relief from symptoms and possibly leading to long-term survival.
Surgery is not recommended for all mesothelioma patients, however, especially if they are in poor health or are diagnosed at a late stage. There are a number of experienced meosthelioma surgeons available for a consult across the country.
Surgery can take place at different points throughout a patient’s experience with mesothelioma. Surgery can be used early on to help make a diagnosis, and it can be used after a diagnosis is made either to eradicate the disease or to relieve symptoms caused by the cancer growth
- Diagnostic Surgery - Diagnostic or exploratory surgery is used to help doctors determine if mesothelioma exists, usually by taking a biopsy. It can be as simple as using a needle or it could require full open surgery, depending on the location of the tumor.
- Curative Surgery - Surgeries that attempt to eradicate the disease are called “curative”. Curative approaches use surgery along with chemotherapy and radiation to try to put the cancer into remission.
- Palliative Surgery - Palliative care focuses on helping the patient relieve symptoms by reducing pain and discomfort. Palliative surgery may remove all or part of the tumor, or addressing symptoms like fluid buildup and inflammation.
The doctors who operate on mesothelioma patients often specialize in the area of the body where the tumors first form. For example, thoracic surgeons – who specialize in surgeries of the chest cavity – may perform surgery on patients with pleural or pericardial mesothelioma. There are also surgical oncologists who specialize in cancer-related surgery.
The purpose of diagnostic surgeries for mesothelioma is to obtain a tissue sample of the pleura, the lining of the lung, especially if a biopsy cannot be obtained by fine-needle aspiration. Diagnostic surgeries can include one or more of the following, depending on the type of mesothelioma and how easy it can be to access the tumor(s).
- Thoracoscopy (pleural)
- Laparoscopy (peritoneal)
- Mediastinoscopy (pericardial)
- Thoracotomy (pleural, pericardial)
- Laparotomy (peritoneal)
Surgery for Pleural Mesothelioma
Several surgical options are available for those pleural mesothelioma, which is the most common form of the disease. These procedures are sometimes followed by chemotherapy or radiation to kill or prevent the growth of remaining cancer tissue.
A pleurectomy involves removal of the pleura (the lining of the lungs). The surgeon will make an incision, through which he will remove both the inner and outer lung linings. Depending on the size of the tumor and whether any metastasis has occurred, the surgeon may remove some of the lung tissue beneath the pleura.
If the mesothelioma only affects one of the lungs, a pneumonectomy may be performed to remove the entire lung. During the surgery, the diseased lung will be deflated and removed through a large incision. It is an intensive surgery that can require up to two weeks in the hospital, and several months until full recovery.
Extrapleural Pneumonectomy (Curative)
In rare cases, in addition to removing the lung, a surgeon will remove the areas surrounding it, including other mesothelial tissue, such as the lining of the heart and/or abdomen, and part or all of the diaphragm. This is an extremely difficult surgery and can result in severe complications.
This procedure is used to remove fluid from around the lungs (pleural effusion), which can make it difficult and painful for mesothelioma patients to breathe. It is usually an outpatient procedure performed by inserting a long, thin needle into the pleural space to withdraw the fluid.
If fluid buildup cannot be controlled by pleurocentesis, a surgeon may insert talc into the pleural space, which will cause inflammation and stop fluid from collecting. It can be an intensive procedure requiring several days in the hospital, and up to two months for full recovery.
Surgery for Peritoneal Mesothelioma
Peritoneal mesothelioma is much less common than pleural, but there are still several types of surgery to treat it or relieve symptoms. In addition to chemotherapy or radiation in multimodal therapies, peritoneal mesothelioma surgery may also be followed by hyperthermic peritoneal chemotherapy (HIPEC) – a warm chemotherapy wash that kills cancer cells in the abdominal cavity.
The lining of the abdomen (peritoneum) is where peritoneal mesothelioma first develops. A peritonectomy removes this lining in an attempt to remove all of the cancerous tissue from the body. Studies have shown this treatment, combined with HIPEC, to have one of the highest success rates of all mesothelioma surgeries.
The abdomen contains a lot of organs, and in many cases mesothelioma can spread to various abdominal organs relatively easily. Cytoreductive surgery attempts to remove all visible tumors. It is intensive surgery, usually taking as long as 10 – 12 hours, and often includes a HIPEC wash.
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When there is fluid buildup in the abdominal cavity (peritoneal effusion), a paracentesis can be performed to remove the fluid and provide comfort to peritoneal mesothelioma patients.
Surgery for Pericardial Mesothelioma
Unfortunately, most cases of pericardial mesothelioma are not discovered until after the patient has already passed away. However, in those cases where a patient is diagnosed in enough time, there are some surgical options available.
Pericardial mesothelioma develops in the pericardium (lining of the heart). In this surgery, the pericardium is removed in an effort to eradicate the cancer. Typically, the pericardium will be replaced with surgical Gore-Tex, so that the heart will continue to pump smoothly.
If fluid accumulates in the heart cavity (pericardial effusion), it can put pressure on the heart, affecting the rhythm and blood pressure. A pericardiocentesis relieves that pressure by draining fluid from the pericardial space.
Further Discussion on Mesothelioma Surgery
Only about 1 in 5 patients with metastatic pleural mesothelioma undergo surgery. There are two main surgeries: pleurectomy/decortication, in which the surgeon tries to remove as much of the tumor from around the lung as possible, and the more radical extrapleural pneumonectomy, in which the lung itself is removed.
Much debate exists as to which surgery is more effective, although studies show that most long-term survivors have undergone some form of surgery. Studies have found that pneumonectomy followed by radiation prevents tumor recurrence in the chest in 80 to 85 percent of patients.
However, it is a long, intensive operation with a 55 percent complication rate and a 3 percent risk of death, higher in some institutions. Therefore, this surgery is only performed for patients with a reasonably good prognosis, when it doesn’t appear that the cancer has spread outside the chest.
Patients best suited for pneumonectomy are younger, with the epithelial form of the disease, no obvious lymph node involvement, and are otherwise healthy enough to withstand the rigor of the procedure.
Pleurectomy/decortication has a higher failure rate, with the tumor recurring in the chest cavity 50 to 80 percent of the time. However, that rate may change with improved radiotherapy techniques. The reason for the high recurrence is that it’s difficult to completely remove the tumor without removing the lung.
However, there is no difference in survival rates between the two surgeries. Part of the reason is that the cancer has often spread to other parts of the body by the time it is diagnosed even if it appears to be confined to the chest.
In the end, part of the debate around the value of surgery is whether many patients who undergo surgery do better because the patients offered it are the very patients most likely to do well regardless of treatment, since surgery tends to be offered far more readily to younger, fit patients with earlier stage disease. There is no randomized trial evidence that demonstrates a significant benefit to surgery over non-surgical management of mesothelioma.Sources
Alexander HR, Hanna N, Pingpank JF. Clinical results of cytoreduction and HIPEC for malignant peritoneal mesothelioma. Cancer Treatment and Research. 2007;134:343-55.
Extrapleural Pneumonectomy. University of California San Francisco web site. Accessed November 10, 2016.
Flores RM. The mesothelioma surgery shift. The Journal of Thoracic and Cardiovascular Surgery. February 2016;151(2):485-486. doi: 10.1016/j.jtcvs.2015.10.054
Morris DL. Peritonectomy HIPEC—contemporary results, indications. Chinese Journal of Cancer Research. August 2013;25(4):373–374. doi: 10.3978/j.issn.1000-9604.2013.07.03
Pass HI, Kranda K, Temeck BK, et al. Surgically debulked malignant pleural mesothelioma: Results and prognostic factors. Annals of Surgical Oncology. April 1997;4(3):215-222. doi: 10.1007/BF02306613
Pleurectomy and Decortication. Baylor College of Medicine web site. Accessed November 10, 2016.