Mesothelioma surgery uses medical procedures to treat this cancer, which affects the protective lining around your body's cavities (mesothelium). Often the goal of surgery is to remove tumors and as much cancerous tissue as possible. Surgery can also reduce symptoms like fluid buildup.
Dr. Jeffrey Velotta: What types of surgeries are available for mesothelioma treatment?
Surgery types available for mesothelioma include two main types. So the first that was originally originated with Dr. Sugarbaker at the Brigham and Women's Hospital was the extrapleural pneumonectomy, otherwise known as EPP. And the idea behind that surgery was that you remove the entire lung and all the pleural surface, the parietal and visceral layer, as well as the diaphragm and the pericardial lining. So that was the kind of first nuanced approach where that was all done.
And then the second, more newer approach, slightly less invasive, and with slightly better results now is called the pleurectomy and decortication. And that's a lung sparing operation where you take all that pleural lining, the mesothelium lining, but save the lung. You still take the heart lining, as well as the diaphragm and the diaphragm lining, but you save the lung.
And I think that's based on clinical trials and multiple studies now, it would be now for surgery, the more gold standard would be pleurectomy and decortication. Since the MARS trial in 2011, we're really seeing the majority of people now doing pleurectomies and decortication versus extrapleural pneumonectomy are kind of in the more rare instances. So pleurectomy and decortication is kind of what I feel is the standard treatment now for surgical management of mesothelioma.
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Dr. Jeffrey Velotta: What types of surgeries are available for mesothelioma treatment?
Surgery types available for mesothelioma include two main types. So the first that was originally originated with Dr. Sugarbaker at the Brigham and Women's Hospital was the extrapleural pneumonectomy, otherwise known as EPP. And the idea behind that surgery was that you remove the entire lung and all the pleural surface, the parietal and visceral layer, as well as the diaphragm and the pericardial lining. So that was the kind of first nuanced approach where that was all done.
And then the second, more newer approach, slightly less invasive, and with slightly better results now is called the pleurectomy and decortication. And that's a lung sparing operation where you take all that pleural lining, the mesothelium lining, but save the lung. You still take the heart lining, as well as the diaphragm and the diaphragm lining, but you save the lung.
And I think that's based on clinical trials and multiple studies now, it would be now for surgery, the more gold standard would be pleurectomy and decortication. Since the MARS trial in 2011, we're really seeing the majority of people now doing pleurectomies and decortication versus extrapleural pneumonectomy are kind of in the more rare instances. So pleurectomy and decortication is kind of what I feel is the standard treatment now for surgical management of mesothelioma.
What Is Mesothelioma Surgery?
Mesothelioma surgery is a treatment using medical procedures to help people with this cancer live longer and better. Doctors often refer to aggressive surgery designed to help people live longer as “curative,” though no surgery can cure mesothelioma yet. Less aggressive procedures that aim to improve symptoms are called palliative surgeries.
Therapeutic mesothelioma surgeries cut out visible tumors. Surgeons also remove as much tissue where mesothelioma cells have spread as possible to help people live longer. Palliative mesothelioma surgeries address issues such as pain, discomfort and trouble breathing with procedures like removing and preventing the fluid from coming back.
Key Facts About Mesothelioma Surgery
Mesothelioma surgery can improve a patient’s prognosis, extend survival and improve the overall quality of life.
About 27.6% of pleural mesothelioma patients received surgery between 2004 and 2020, according to the National Cancer Database.
About 50% to 69% of peritoneal patients who undergo cytoreductive surgery with heated chemotherapy live longer than 5 years.
Pain and swelling around the incision are the most commonly reported complications of surgery.
Surgery is often part of multimodal therapy plans for mesothelioma. Doctors may recommend chemotherapy to kill any remaining cancer cells after surgery and radiation to prevent local recurrence. Immunotherapy may help as a maintenance therapy. These mesothelioma treatments improve the chance of long-term survival in combination with surgery.
Types of Surgery for Mesothelioma
In addition to curative and palliative procedures, other types of surgery for mesothelioma include diagnostic, staging and supportive surgeries. Each of these can play an important role in your mesothelioma journey.
Dr. Jacques Fontaine, thoracic surgeon and director of the Mesothelioma Research and Treatment Center at Moffitt Cancer Center in Tampa, told us, “There’s two categories of surgery we can offer. Palliative surgery’s goal is to improve quality of life. The goal of curative surgery for mesothelioma is to remove all the disease that can be seen with the naked eye.”
List title: Common Curative Types of Mesothelioma Surgery
Cytoreductive surgery with HIPEC: This curative surgery for peritoneal mesothelioma removes visible tumors before applying heated chemo directly to the abdomen.
Extrapleural pneumonectomy: This surgery for pleural mesothelioma removes the entire lung. Because EPP is a very aggressive surgery, surgeons perform it less often than lung-sparing surgeries.
Pericardiectomy: Also known as a pericardial window, this surgery for pericardial mesothelioma removes part or all of the heart’s lining to take out tumors or relieve fluid buildup. It may improve symptoms and extend life.
Peritonectomy: A peritonectomy is an aggressive surgery that removes visible tumors from the abdominal lining to treat peritoneal mesothelioma. A type of cytoreductive surgery, it’s often paired with HIPEC.
Pleurectomy with decortication: While P/D is an aggressive surgery for pleural mesothelioma, it’s a lung-sparing surgery. It’s considered less aggressive than EPP and doctors perform it more often.
Diagnostic surgeries include surgical biopsy, which is a procedure where a surgeon removes part or all of a lump or abnormal tissue through a small cut to help diagnose mesothelioma. It may be done in a hospital or clinic using local or general anesthesia, and the removed tissue is sent to a lab for testing. Staging surgery helps doctors see how far mesothelioma has spread in the body. It may involve procedures like laparoscopy or endobronchial ultrasound/mediastinoscopy, where a small camera is used to look inside and take tissue and lymph node samples.
Supportive surgery for mesothelioma is similar to palliative surgery in that it doesn’t remove tumors or aim to be curative. Its goal is to help other mesothelioma treatments work better. An example of a supportive surgery is placing a catheter or port to deliver chemo more effectively.
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Pleural mesothelioma surgeries are often part of multimodal therapy, which combines major, tumor-removing surgery with other treatments, including radiotherapy and chemo. This aggressive treatment approach can extend life expectancy.
Pleural Mesothelioma Surgeries
EPP: An entire lung, the lining around it (possibly including the diaphragm and pericardial layers) and nearby lymph nodes are removed.
Partial pleurectomy: Part of the pleura, the thin lining around the lungs, is removed to take out visible mesothelioma tumors and ease symptoms like shortness of breath. It’s less aggressive than removing the entire pleura and may be offered when full tumor removal isn’t possible.
P/D: The pleural lining around the lungs (possibly including the diaphragm and pericardial layers) and all visible tumors are removed as well as nearby lymph nodes. Surgeons scrape the surface of the diseased lung rather than removing the organ.
Pleurodesis: It seals the space between the lung and chest wall to prevent fluid or air from building up again. It causes inflammation that fuses the layers of the pleura together.
PleurX catheter placement: Surgical placement of a small silicone catheter, called a PleurX, allows you to drain pleural fluid at home every 2 to 3 days without having to undergo another thoracentesis.
Thoracentesis: A doctor can drain pleural fluid with a hollow needle to relieve chest pressure, allowing the lungs to expand to improve breathing.
About 15% to 20% of patients with pleural mesothelioma qualify for aggressive surgery. Specialists will recommend the treatment for mesothelioma that best meets your needs and goals. When deciding between pleurectomy versus pneumonectomy, for example, surgeons will consider your unique medical needs and preferences. These surgeries may take several hours to complete, and recovery time varies depending on the procedure.
Pleurectomy With Decortication (P/D)
The goal of pleurectomy and decortication is to take out as much cancer as possible without removing the lung. Doctors offer P/D to people with pleural mesothelioma that hasn’t spread too far into the lung or nearby tissue. You must be strong enough to handle surgery and recovery.
P/D may help people live longer. It’s less invasive than other surgeries and keeps the lung in place, which helps you breathe better. But there are some risks. You may have bleeding, air leaking, infection or pain after surgery. Recovery takes time, but many people feel better as they heal. Doctors and nurses will help you manage side effects.
The median survival is 22 months. A 2024 long-term survival analysis published in the journal Clinical Lung Cancer found the P/D group had 10-year overall survival rates of 16%, significantly higher than any other group.
Extrapleural Pneumonectomy (EPP) for Mesothelioma
The goal of extrapleural pneumonectomy is to take out as much cancer as possible. EPP removes one lung, the lung lining, part of the diaphragm/pericardium and some nearby tissue.
Doctors may recommend it when the mesothelioma hasn’t spread far and you’re strong enough for surgery. Your doctor will check your overall health, lung strength and if the cancer is only on one side of your chest. If your heart and other lung are healthy, you may be able to have an EPP. Doctors also check to see if other treatments, like chemo or radiation, will help after surgery.
Benefits include improved symptoms, and median survival after EPP is about 15 months. It may remove most of the cancer and give other treatments a better chance to work. But there are risks. You will lose one lung, so breathing may be harder. Recovery takes a long time and may include pain, fatigue and shortness of breath. These risks are why doctors don’t often perform EPP today and typically recommend lung-sparing surgeries.
Michael Cole
Verified Asbestos.com Survivor
Don’t Be Afraid of Aggressive Mesothelioma Treatment
When I was diagnosed with malignant pleural mesothelioma my specialist told me extrapleural pneumonectomy surgery with heated intrathoracic chemotherapy, or HITHOC, was the best course of action for my case. I said, ” I want you to get everything you can see, everywhere you think it might be hiding and everywhere you think it might go.” He was visibly relieved when I told him that.
Peritoneal Mesothelioma Surgery Options
The most effective and aggressive surgery for peritoneal mesothelioma is cytoreductive surgery with HIPEC. People with good overall health and cancer that hasn’t spread too far often qualify. The procedure helps patients live between 38 to 67 months. Approximately 50% of peritoneal mesothelioma patients qualify for tumor-removing surgery.
Surgeries for Peritoneal Mesothelioma
Omenectomy: This is typically done during cytoreductive surgery with HIPEC. An omentectomy removes an apron of the peritoneum called the omentum to remove as much cancerous tissue from your body as possible.
Paracentesis: This is a palliative surgery commonly performed to drain excess fluid buildup. To avoid the need for multiple paracenteses, sometimes small, flexible tubes or indwelling peritoneal catheters (tunnel or PeritX) are inserted to drain fluid. They can be left in place, allowing you to manage ascites at home.
Peritonectomy: This is done during cytoreductive surgery. Peritonectomy removes diseased parts of the peritoneum, the lining around the cavity and organs in your belly.
Dr. W. Charles Conway, who directs surgical oncology at the Ridley-Tree Cancer Center, tells us “I think the best treatment for peritoneal mesothelioma is a combination of HIPEC as well as what we call a cell reductive procedure. This includes the peritonectomy procedure.”
Benefits of cytoreductive surgery and HIPEC include improved symptoms and longer survival. Repeat HIPEC with surgery patients live 67.7 months or 5.6 years, according to a 2022 study published in Annals of Surgical Oncology. Risks include infection, digestive issues, excessive bleeding and constipation.
Pericardial Mesothelioma Surgery Options
Surgeries for pericardial mesothelioma include pericardiectomy and pericardiocentesis. They involve removing affected tissue or draining fluid buildup. These procedures have varying success rates and tend to have higher risks of serious complications.
Surgeries for Pericardial Mesothelioma
Pericardiectomy: Removes as much cancerous tissue as possible from the heart lining, or pericardium. It can relieve symptoms such as difficulty breathing, chest pressure, heart palpitations and fatigue.
Pericardiocentesis: Similar to thoracentesis and paracentesis, but the fluids are removed from around the heart rather than the lungs or abdomen. Doctors treat recurrent pericardial effusions with repeat pericardiocentesis procedures.
These procedures can improve quality of life and relieve symptoms like shortness of breath, coughing and chest pressure. Risks include infection, abnormal heart rate and cardiac arrest. After you get home from surgery, you should contact your doctor if draining from the incision increases or you notice chest pain or severe symptoms.
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The most common treatment for testicular mesothelioma is inguinal orchiectomy, a surgery to remove one or both testes along with the spermatic cord. The risks include bleeding, infection, swelling and pain.
A urologic oncologist, a specialist in cancers of the urinary tract and reproductive system, typically performs the surgery. The surgeon may also perform a lymphadenectomy to remove nearby affected lymph nodes.
Disease-specific survival rates are higher among testicular patients compared to pericardial patients. About 58% survive 5 years after diagnosis, with 45% surviving 10 years. Disease-specific survival measures how many people die from the cancer compared to other causes.
The statistics about surgery are based on clinical research and apply only to people diagnosed with different types of mesothelioma cancer. These statistics don’t reflect other surgery stats for the population at large.
Who Is Eligible for Mesothelioma Surgery?
You may be eligible for mesothelioma surgery if you’re in good overall health and your doctor is confident you can recover from potential complications. You may not qualify if you have the biphasic or sarcomatoid cell type, late-stage cancer or certain preexisting conditions. Speaking with a surgeon is important to determine if you meet the criteria.
Mesothelioma Surgery Eligibility Criteria
Cancer stage and cell type
Cardiac health
Comorbidities like high blood pressure and diabetes
Overall health
Past surgical history
Smoking status
Eligibility for surgery is thoroughly vetted during a surgical consultation, where the surgeon and the surgical team review your medical history, imaging scans and biopsy results. If you qualify for surgery, you also may be able to join a mesothelioma clinical trial of other treatment options. Mesothelioma surgeons can offer patients the opportunity to participate in clinical trials to investigate the best therapies to combine with surgery.
Benefits of surgeries for mesothelioma include longer survival and improved symptoms. Pleural surgery reduces chest pain and improves breathing and coughing. Peritoneal surgery improves abdominal pain and swelling as well as digestive symptoms such as constipation. Surgery offers the potential for long-term survival in select cases.
It’s important for surgical candidates to speak with their surgeons about the risks and benefits of different procedures. The most common complications of mesothelioma surgery are pain and swelling around the incision and air leaking. The risks vary by the type of surgery and the patient’s health. Addressing complications quickly is important throughout the recovery process.
Mesothelioma Surgery Complications
Air leaking
Bleeding
Cardiac complications
Dry cough
Fatigue
Infection
Pain after surgery
Pneumonia
More than a decade after her mesothelioma surgery, Susan Dickman tells us the benefits were worth it. She developed an infection 6 weeks after, but it was her only complication.
Susan says, “My husband helped me and my kids. God, all of them helped and got me back to normal.” She says she doesn’t have any lingering side effects and hasn’t had a cancer recurrence.
What to Expect During Recovery
Everyone has a different mesothelioma surgery recovery process depending on the surgery they’ve had, their overall health and whether any complications arise. How long it takes you to recover and the amount of pain you feel will depend on the extent of your procedure.
The recovery process varies for people who undergo chemo or radiation after surgery. Doctors often tailor multimodal therapy plans. Some people may receive additional therapies soon after surgery, while others may need several weeks of recovery.
Tips for Managing Recovery After Mesothelioma Surgery
Take your medicine: Always take your pain medicine as your doctor says. This will help you feel better and rest more.
Get plenty of rest: Your body needs time to heal. Take naps and don’t do too much too fast.
Do breathing exercises: Use your breathing tool or take deep breaths every day. This helps your lungs get stronger and prevents infections.
Eat healthy foods: Try to eat fruits, vegetables and protein like chicken or eggs. Good food helps your body heal faster.
Move a little each day: Take short walks or move around a bit when your doctor says it’s safe. This helps with energy and keeps your blood moving.
Tell your doctor about new problems: If you feel worse or have trouble breathing, tell your care team right away. They can help.
Recovery from P/D takes about 3-4 months. Recovery may take longer for people who have more aggressive surgeries such as the EPP and HIPEC. When we asked Dr. Jacques Fontaine about EPP surgery, he said the EPP “is a tough recuperation that can take 3 to 6 months.”
Your surgical team will provide guidance to help you understand how to prepare for the recovery process at home. They’ll also schedule follow-up care for imaging scans to monitor the outcome of your surgery. Be careful to follow any instructions, attend all medical appointments and rehabilitation therapy sessions to help your recovery.
What to Do if You’re Considering Mesothelioma Surgery
Before undergoing surgery for mesothelioma, talk to your surgeon to make sure you understand the risks and benefits of the procedure. Ask questions about how the procedure may affect your body, quality of life and lifespan to make an informed decision about mesothelioma surgery.
Questions to Ask Your Doctor
What surgical option is best for me?
What are the benefits of this procedure?
What risks could I face if I choose to have this surgery?
What can I do to reduce my risks of complications?
How can I best prepare for surgery and recovery?
Prepare for surgery based on the guidelines your surgical team provides. Planning for the recovery process involves building a good support team at home and making sure your caregivers are prepared to help. Talk to your doctors about follow-up appointments to see if your surgery was successful.
Mesothelioma survivor Michael Cole tells us help from caregivers got him through the first phase of recovery.He shares, “You will be largely dependent upon your caregivers at home for several weeks after surgery. The situation will improve, and after a few weeks you will be able to carry more of the load yourself.”
Michael adds. “With time, it is possible to recover most of one’s abilities, although with a few limitations. Don’t lose hope and never give up!”
Common Questions About Surgery for Mesothelioma
Can mesothelioma be removed with surgery?
Yes, aggressive surgeries attempt to remove early-stage mesothelioma completely, but some microscopic cancer cells are often left behind. Chemotherapy and radiation may help to kill the remaining cancer cells.
How successful is surgery for mesothelioma?
About 24% of early-stage mesothelioma patients live at least 5 years after surgery. An EPP and P/D have a risk of failure with mortality rates around 11% and 3.1%, respectively.
What is the prognosis for mesothelioma surgery?
For early-stage mesothelioma patients who undergo aggressive surgery, the prognosis can be more favorable compared to those with advanced-stage disease. Surgery is often part of a multimodal treatment approach, and other therapies impact the prognosis as well.
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Dr. Jacques Fontaine is a thoracic surgeon at Moffitt Cancer Center in Tampa, Florida, where he heads up the Mesothelioma Research and Treatment Center. He specializes in minimally invasive robotic surgery and aggressive surgeries for mesothelioma.
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