A pleural mesothelioma surgical consult is the most consequential conversation in your treatment plan. Walking in with the right questions helps you understand your options, compare procedures and leave with a clear surgical plan.
Dr. Jeffrey Velotta: Why See a Mesothelioma Specific Surgeon
I really urge you to see mesothelioma surgeon experts, not just a regular thoracic surgeon. Not that a regular thoracic surgeon's not a good surgeon, it's that mesothelioma, it matters how many you've done in the experience because it is so rare. Most surgeons will never see mesothelioma, so they won't necessarily be able to tell you, oh, you'll get a pleurectomy and decortication, or This is the chance that you'll get a pleurectomy and decortication, or This is the chance that we'll be able to remove it. In doing these for the last ten years and having training under Doctor.
Sugarbaker, I kind of have a sense of that. And my sense is that almost always you can do pleurectomy decortication. No matter how aggressive it's growing into the lung, it'll peel off. Yeah, sure, it's a little harder of an operation.
May take an extra hour longer, but if you can save the lung and peel it off of the pleurrectomy and decortation, there has been data for that, and we see that. Those patients recover much better If you are asking about treatment options, you need to ask that doctor, whether it's a medical oncologist, a radiation oncologist, a pulmonologist, a primary care doctor, thoracic surgeon, do you see How often do you see meso? We often get scared about it when it comes to other things, like you wouldn't think about it for high blood pressure, and that's reasonable because high blood pressure's very common.
Most people see that. Or for breast cancer. It's the most common cancer in women, so maybe you shouldn't you don't necessarily need to ask that from your oncology because it's so common. Mesothelioma is one of the rarest cancers, in the world, but also the most, like, one of the most aggressive cancers.
And there's so many different treatment options for it. You need people on your side that's gonna be the most experienced? So that's the question I ask. The other question that I ask or that they should ask is, Have I ever been presented in a tumor board?
Mesothelioma, I think it's really important to be presented in a tumor board. What does that mean? Not just your regular tumor board. Every hospital pretty much has a tumor board where you have different sets of doctors that just weigh in on your cancer diagnosis about what to do. Mesothelioma, your tumor board only means something if it's from specialists in radiology, radiation oncology, medical oncology, thoracic surgery, pulmonology, that have expertise in mesothelioma. It is almost like its own entity of thoracic surgery.
And so it should be, in my opinion, brought up to a multidisciplinary tumor board, but specializing in mesothelioma. Meaning, I'll give you an example, if you just give it to a regular tumor board, that's just like not getting a tumor board opinion at all because they won't have the expertise in that. And then it's almost even worse because that patient may go with what that tumor board said and they had no idea of the standard of care of what it would be for mesothelioma, that's just their classic checking off the box, they saw a tumor board, They saw a tumor board, this is what it is. So I think that's really the third thing that I would emphasize.
Dr. Jeffrey Velotta: Why See a Mesothelioma Specific Surgeon
I really urge you to see mesothelioma surgeon experts, not just a regular thoracic surgeon. Not that a regular thoracic surgeon's not a good surgeon, it's that mesothelioma, it matters how many you've done in the experience because it is so rare. Most surgeons will never see mesothelioma, so they won't necessarily be able to tell you, oh, you'll get a pleurectomy and decortication, or This is the chance that you'll get a pleurectomy and decortication, or This is the chance that we'll be able to remove it. In doing these for the last ten years and having training under Doctor.
Sugarbaker, I kind of have a sense of that. And my sense is that almost always you can do pleurectomy decortication. No matter how aggressive it's growing into the lung, it'll peel off. Yeah, sure, it's a little harder of an operation.
May take an extra hour longer, but if you can save the lung and peel it off of the pleurrectomy and decortation, there has been data for that, and we see that. Those patients recover much better If you are asking about treatment options, you need to ask that doctor, whether it's a medical oncologist, a radiation oncologist, a pulmonologist, a primary care doctor, thoracic surgeon, do you see How often do you see meso? We often get scared about it when it comes to other things, like you wouldn't think about it for high blood pressure, and that's reasonable because high blood pressure's very common.
Most people see that. Or for breast cancer. It's the most common cancer in women, so maybe you shouldn't you don't necessarily need to ask that from your oncology because it's so common. Mesothelioma is one of the rarest cancers, in the world, but also the most, like, one of the most aggressive cancers.
And there's so many different treatment options for it. You need people on your side that's gonna be the most experienced? So that's the question I ask. The other question that I ask or that they should ask is, Have I ever been presented in a tumor board?
Mesothelioma, I think it's really important to be presented in a tumor board. What does that mean? Not just your regular tumor board. Every hospital pretty much has a tumor board where you have different sets of doctors that just weigh in on your cancer diagnosis about what to do. Mesothelioma, your tumor board only means something if it's from specialists in radiology, radiation oncology, medical oncology, thoracic surgery, pulmonology, that have expertise in mesothelioma. It is almost like its own entity of thoracic surgery.
And so it should be, in my opinion, brought up to a multidisciplinary tumor board, but specializing in mesothelioma. Meaning, I'll give you an example, if you just give it to a regular tumor board, that's just like not getting a tumor board opinion at all because they won't have the expertise in that. And then it's almost even worse because that patient may go with what that tumor board said and they had no idea of the standard of care of what it would be for mesothelioma, that's just their classic checking off the box, they saw a tumor board, They saw a tumor board, this is what it is. So I think that's really the third thing that I would emphasize.
Questions About Your Eligibility for Pleural Mesothelioma Surgery
Not everyone with pleural mesothelioma is a candidate for surgery. Eligibility comes down to how far the cancer has progressed, what cell type it is and whether your lungs and overall health can handle a major operation.
Surgery is not the only treatment option available to pleural mesothelioma patients. Chemotherapy, immunotherapy and clinical trials are other options that can manage or lessen cancer symptoms. Talk with your surgeon to weigh which option is best for you or visit a specialty center for a second opinion.
Am I a candidate for surgery based on my stage and cell type?
Your mesothelioma stage and cell type are important factors in whether surgery is the right option for you. Surgery for pleural mesothelioma is generally considered for patients in the earlier stages of the disease, before it has spread. Mesothelioma cell type also plays a big role. Epithelioid cells respond best to surgery, while sarcomatoid and biphasic cases often call for systemic therapy first. A clear answer from your surgeon will reference your specific stage and cell type. If there is still uncertainty in whether surgery is right for you, ask if additional staging tests could help clarify things.
What pre-surgical tests will I need, and what will they tell us?
Pulmonary function tests, cardiac evaluation, additional imaging like a PET-CT and sometimes more involved staging procedures are common pre-surgical tests your pleural mesothelioma surgeon can order. These tests can confirm the progression of your cancer, what the outcome of the surgery may be and if your heart and lungs can sustain the stress of the operation. Ask your surgeon to walk you through which tests you’ll need, what each one is looking for and what the overall timeline looks like.
If I’m not a surgical candidate today, what would change that?
Sometimes surgery is too risky or dangerous at the moment, but that does not mean it is no longer an option. A neoadjuvant approach uses chemotherapy or immunotherapy to shrink a tumor enough to make mesothelioma surgery possible in the future. Ask your surgeon whether your case could get there, what the criteria would be and how long it might take.
Questions to Get to Know Your Pleural Mesothelioma Surgeon
Familiarizing yourself with your mesothelioma surgeon will help you build trust in your treatment plan. Each mesothelioma case has a different treatment plan with several factors like age, stage or cell type. Surgery is a strong treatment option for some mesothelioma patients, but it is crucial to familiarize yourself with your surgeon before discussing any procedures. Your doctor’s experience, their recommended plan of treatment and a walkthrough of the surgical process can help build trust in your surgical plan.
Pleural mesothelioma is a rare illness with about 3,000 people diagnosed each year in the U.S. Surgical outcomes are closely tied to how much experience a surgeon has with this specific cancer. You should know your surgeon is the right fit for your case before any decisions about surgery are made.
How many pleural mesothelioma surgeries have you personally performed?
A general thoracic surgeon is a skilled doctor, but pleural mesothelioma procedures are technically demanding. It’s rare enough that some surgeons have only handled a small number of cases. A surgeon with experience with several mesothelioma cases will be able to guide you through the surgical process with ease and quickly make critical decisions. If a surgeon only has experience with a small handful of mesothelioma cases, seek a second opinion at a specialty center.
Expert Insight
“I really urge you to see mesothelioma surgeon experts, not just a regular thoracic surgeon. Not that a regular thoracic surgeon’s not a good surgeon, it’s that mesothelioma, it matters how many you’ve done in the experience because it is so rare.”
Dr. Jeffrey Velotta
Will my case go to a multi-disciplinary tumor board?
A tumor board is a strategy session that brings together surgeons, oncologists, radiologists and pathologists to review your case as a team. Multi-specialty input is crucial for a cancer as rare as pleural mesothelioma. A good answer is clear and specific: your case will be reviewed at a scheduled tumor board meeting.
Will you personally re-review my pathology slides and imaging?
Your surgeon should review your pathology slides with your pathologist before moving forward with a surgical plan. Pathology slides are specimens of tissue that are examined and evaluated. A written report of slides is an interpretation of what your pathologist saw. Your surgeon should have a clear understanding of your case before moving forward.
There are 2 surgeries used for pleural mesothelioma. Pleurectomy with decortication removes the diseased lung lining while preserving the lung. Extrapleural pneumonectomy removes the lung itself along with the lining, diaphragm and pericardium.
P/D vs EPP
Pleurectomy/Decortication
Removes the diseased pleura
Preserves the lung
Lower mortality risk
Preferred approach at most high-volume mesothelioma centers
Typically considered for earlier-stage epithelioid patients with adequate lung function
Extrapleural Pneumonectomy
Removes the lung, pleura, diaphragm and pericardium
More aggressive operation
Higher mortality risk
Considered for select cases where P/D can’t achieve adequate removal
P/D and EPP aren’t interchangeable. Most high-volume mesothelioma centers favor P/D when it’s feasible, because outcomes are comparable and recovery tends to be more manageable. Your surgeon should be able to explain which approach fits your specific stage, cell type and lung function.
Which procedure are you recommending for me, and why?
The right procedure for you will depend on your specific cell type, stage, lung function and overall health. Your surgeon can explain which option is best for you based on where the disease has spread and how well your body can handle the procedure. At most modern specialty centers, P/D is the starting point when it’s feasible. However, EPP may be your best option.
What are the risks, complications and mortality rate of this surgery for someone with my profile?
Both P/D and EPP generally have risks including bleeding, infection, prolonged air leak, pneumonia, blood clots and operative mortality. Ask your surgeon for both their personal complication and mortality rates for patients with your stage and cell type, as well as general published figures.
Will surgery be combined with chemo, radiation or immunotherapy, and in what order?
Most people with pleural mesothelioma who have surgery follow up with post-operative procedures. Chemo, immunotherapy or radiation can be included before the operation, after the operation or both. Multimodal therapy combines more than one method of treatment for optimal results. Ask your surgeon to walk you through the full sequence, who manages each phase and the reasoning behind the order. You can also ask your surgeon whether any mesothelioma clinical trials fit into your plan.
Questions About Recovering From Pleural Mesothelioma Surgery
Most patients spend 1 to 2 weeks in the hospital after pleural mesothelioma surgery. Procedures generally involve recovery at home and a pulmonary rehabilitation program. Discussing post-operative recovery can better prepare you and your caregiver.
Recovery from pleural mesothelioma surgery generally involves a hospital stay, caregiver support at home and rehabilitation in the months following. Knowing what your recovery process will look like and the full length of your recovery time can affect your decisions surrounding surgery. You can talk to your surgeon about the timeline of your recovery.
What does recovery actually look like in terms of hospital stay, time off work and pulmonary rehab?
Ask your surgeon for a realistic timeline of the entirety of your surgery experience. How many days in the ICU, how long in the hospital overall, when chest tubes typically come out and what the return-to-work timeline looks like are all fair questions. Pulmonary rehabilitation is also typically part of recovery, so ask how that fits in and what it involves.
Dr. Jeffrey Velotta, a thoracic surgeon who specializes in mesothelioma, shares his advice for caregivers: “A loved one, when they’re advocating for the patient, they need to be at the visit. If it’s a virtual visit, fine. But be on the Zoom call or be on the phone. You need the family members as a caregiver there.”
What support will I need at home, and for how long?
Most people need a full-time caregiver for at least the first few weeks after pleural mesothelioma surgery. A caregiver is generally there to help with medications, wound care and getting to follow-up appointments. There are also physical restrictions to plan around, like lifting and driving limitations.
Ask your surgeon what to expect day to day, what home equipment you might need and what home-health services your insurance is likely to cover. A Patient Advocate can help you coordinate a lot of this before leaving the hospital.
What are the signs that something is wrong after surgery, and who do I call?
Common warning signs after pleural mesothelioma surgery include fever, sudden shortness of breath, swelling in the calves, wound drainage or redness and severe chest pain. Ask your surgeon for a written list and clear instructions on who to contact for each situation.
What to Ask Before You Agree to Pleural Mesothelioma Surgery
Before you say yes to any pleural mesothelioma surgery, you are encouraged to ask any questions to develop a full understanding of the procedure and its implications. While surgery can be an option for your case, it is not the only option.
Knowing the goals of the procedure, your options and clinical trials you are eligible for can change your treatment plan. Pleural mesothelioma surgery can be in efforts to cure, contain or ease symptoms. You may be eligible for other treatments or clinical trials and discussing your options through a second opinion can enable you to make a secure decision on your treatment plan.
Experience From a Mesothelioma Survivor
“Well one of the hardest decisions for me to make related to my mesothelioma was a type of treatment that MD Anderson was recommending and it was approved by the tumor board and that dealt with radiation therapy.”
Kevin Hession, pleural mesothelioma survivor
What is the goal of this surgery for me: cure, control or symptom relief?
Curative-intent surgery aims to remove the cancer and make long-term control possible. It is usually as part of a broader multimodal treatment plan. Disease-control surgery slows progression and focuses on quality of life. Palliative surgery, which is less common with pleural mesothelioma, targets symptoms like pleural effusion rather than the cancer itself. Ask your surgeon to name the goal directly with an honest picture of what surgery is meant to do for you specifically.
Should I get a second opinion before I decide?
You can get a second opinion before deciding on surgery and some medical professionals encourage it. For pleural mesothelioma surgery, a second opinion at a specialty center is standard practice. A Patient Advocate can match you with a high-volume mesothelioma center based on your location, insurance and whether any clinical trials are worth exploring. You can ask your surgeon to forward your records, including your pathology slides and imaging. A Patient Advocate can help you find the right center based on your location, insurance and whether any clinical trials are worth considering.
Exclusive Content | Missy Miller, medical outreach director for The Mesothelioma Center: “As a patient, when you’re trying to find out what the best treatment is for you, make sure you actually seek a specialist in mesothelioma. An oncologist that actually understands the disease, knows how to order different scans.”
What clinical trials should I consider before or instead of standard surgery?
New surgical techniques, neoadjuvant immunotherapy regimens and combination protocols are being tested in active pleural mesothelioma trials right now. Ask your surgeon what trials are open at their institution and discuss any trial opportunities at your specialty center. Eligibility can close after certain mesothelioma treatments, so it’s worth asking before you start standard care.
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Other Common Questions to Ask Your Pleural Mesothelioma Surgeon
What is the most important question to ask a pleural mesothelioma surgeon?
The single most important question is how many pleural mesothelioma surgeries the surgeon has personally performed. Outcomes for this rare cancer are closely tied to how much experience a surgeon has with it specifically. From there, ask whether your case will go to a tumor board and whether the surgeon will re-review your pathology slides and imaging firsthand.
What is the difference between P/D and EPP surgery?
Pleurectomy with decortication removes the diseased lung lining while preserving the lung. Extrapleural pneumonectomy removes the lung itself along with the lining, diaphragm and pericardium. Most modern mesothelioma centers favor P/D when feasible, since outcomes are comparable and recovery is generally more manageable. The right procedure for you depends on your stage, cell type and overall lung function. Your surgeon should walk you through both options and explain the reasoning behind their recommendation.
Are veterans eligible for VA-covered pleural mesothelioma surgery?
Yes. Veterans who were exposed to asbestos during their service may qualify for VA-covered surgery, including referral to specialty centers when needed. The VA has resources specifically for veterans with mesothelioma and benefits can extend beyond surgery to cover other parts of treatment also.
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