What Is Mesothelioma Surgery?
Mesothelioma surgery is a procedure in which a surgeon removes cancer from your body. The goal is to help you feel better and live longer. Aggressive surgery, in combination with chemotherapy and sometimes radiation, is considered the best treatment for mesothelioma because it offers the greatest chance of long-term survival.
Mesothelioma surgeons may recommend surgery to diagnose the disease, remove tumors or improve symptoms. Patients may have several surgical options that vary depending on the type of mesothelioma malignancy, cancer stage and the goal of the procedure.
Not all mesothelioma patients are eligible for aggressive surgeries. However, most patients qualify for palliative surgery. It is less aggressive and can improve symptoms and quality of life. Before surgery, mesothelioma doctors assess each candidate to make sure they are healthy enough to undergo the procedure. Doctors examine lung and heart health with pulmonary function and cardiac stress tests.
Different surgical options are available at all mesothelioma stages. You may be eligible for surgery if your health is good and your doctor is confident you can recover from potential surgery complications. You may not qualify if the tumors have the sarcomatoid cell type or have spread too far. It is important to speak with a surgical specialist to determine if you meet the criteria.
Doctors vet eligibility for surgery during a surgical consultation. The surgical team reviews a patient’s medical history, imaging scans and biopsy results. Patients meet with the surgeon to discuss everything about the procedure.
Mesothelioma surgery is neither curative nor free of risks and side effects. It offers significant improvements in survival time, mesothelioma symptoms and quality of life. These procedures are complex. The nation’s top cancer centers offer them using the latest technologies such as robotic surgery.
Types of Mesothelioma Surgery
Mesothelioma surgery is performed to diagnose disease, remove tumors (aggressive surgery or tumor-removing surgery) or improve symptoms (palliative surgery). Surgeons use more aggressive surgeries on people diagnosed in early stages of mesothelioma. About 15% to 20% of patients with pleural mesothelioma qualify for aggressive surgery.
The most aggressive surgeries for pleural mesothelioma include pleurectomy and decortication and extrapleural pneumonectomy. The most effective and aggressive surgery for peritoneal mesothelioma is a peritonectomy with heated chemotherapy, known as HIPEC. These surgeries may take several hours to complete and recovery time varies depending on the procedure.
Multimodal therapy combines major, tumor-removing surgery with other treatments. Other therapies include radiotherapy and chemotherapy. This aggressive treatment approach can extend life expectancy. Some cases have entered remission.
Extrapleural Pneumonectomy (EPP)
This aggressive surgery removes an entire lung, the lining around it and nearby lymph nodes. It also removes parts of the diaphragm and the lining around the heart, called the pericardium.
Theoretically, EPP offers the best chance to remove all cancer cells for people with pleural mesothelioma. Benefits include improved symptoms and survival. However, it is an intense procedure and permanently reduces the patient’s stamina and strength because an entire lung is removed. Other complications include abnormal heartbeat, blood clots and fluid buildup in the lungs.
A 2017 study at the Baylor Scott & White Medical Center in Temple, Texas, investigated the effect of a combination of EPP and intensity modulated radiation therapy on patients with pleural mesothelioma. The researchers reported a median survival of 38.2 months and a median relapse-free survival of 24.4 months.
Pleurectomy and Decortication (P/D)
P/D surgery was developed as a less aggressive alternative to removing an entire lung for pleural mesothelioma patients. Surgeons remove the pleural lining around the lungs and all visible tumors. They scrape the surface of the diseased lung rather than removing the organ.
A benefit to this procedure is keeping the affected lung. Approximately 90% of patients experience reduced symptoms. Risks include prolonged air leak, infection, excessive bleeding, cardiac complications and respiratory failure. P/D and EPP offer similar survival outcomes. EPP has a median overall survival of 12 to 22 months compared with 13 to 29 months for P/D.
Debulking (Partial Pleurectomy)
A partial pleurectomy, sometimes called debulking, aims to remove as much tumor tissue as possible when the tumor cannot be completely removed. Pleural mesothelioma patients in otherwise good health may be eligible for this procedure.
A partial pleurectomy involves opening the chest cavity and removing the outside of the pleural layer that lines the chest wall and lungs. It treats mesothelioma by removing all visible cancerous tissue.
Complications that may occur with a partial pleurectomy include air leak, bleeding, cardiac issues, infection, pneumonia, respiratory failure and post-operative pain. A pleurectomy has a risk of failure with a mortality rate around 3.1%.
Other Surgeries for Mesothelioma
Typically, surgery is more successful as a mesothelioma treatment option in the early stages when cancer has not yet metastasized to distant sites in the body. Surgeons use aggressive surgery in the early stages for this reason.
While palliative surgeries are less aggressive procedures, they still carry risks. Mesothelioma surgeries are difficult procedures to undergo, but they offer the best chances of improving a patient’s quality of life and prognosis.
Pleural Mesothelioma Surgeries
Pleural mesothelioma has the most surgical options, but these procedures are less effective than surgeries for peritoneal patients. These surgeries can be matched to best meet the patient’s needs and treatment goals. The following palliative surgeries help control symptoms for people with late-stage mesothelioma, and some people live longer thanks to these procedures.
- Pleurodesis: This procedure is used to drain fluid buildup between layers of the pleura. It may be performed as a one-time procedure or repeated multiple times to control fluid buildup around the lungs. In a talc pleurodesis, a surgeon uses medical-grade talc during the procedure to cause the lung to stick to the chest wall, decreasing the likelihood of the pleural fluid returning.
- Thoracentesis: A doctor can drain pleural fluid through a hollow needle to relieve pressure and make it easier to breathe. Risks include pain at the incision site and infection. This is an outpatient procedure performed under local anesthesia. The pleural fluid can also be tested for cancer cells as part of the diagnostic process.
- PleurX Catheter Placement: Surgical placement of a small silicone catheter, called a PleurX, allows the patient to drain pleural fluid at home every two to three days without having to undergo another thoracentesis. A home health nurse will teach the patient how to perform this drainage.
- Thoracoscopy: Also called video-assisted thoracoscopic surgery, or VATS, this diagnostic procedure involves inserting a small camera and a long, thin probe through small incisions between the ribs to take biopsy samples. The video component allows the surgeon to see the extent of the disease and exactly where to retrieve the best biopsies.
Peritoneal Mesothelioma Surgeries
Nearly 40% of peritoneal mesothelioma patients qualify for tumor-removing surgery. The most effective treatment for this disease combines a peritonectomy with HIPEC.
A patient’s Peritoneal Cancer Index score, which measures how far cancer has progressed, can predict how well they will respond to surgery. According to a 2020 study published in Scientific Reports, patients with a low score respond best to surgery.
- Peritonectomy: In this procedure, surgeons remove the diseased parts of the peritoneal lining of the abdomen. This procedure may involve removing parts of the liver, pancreas, spleen, gallbladder, bowels and stomach. Benefits include improved symptoms and longer survival when a peritonectomy is combined with a cytoreductive surgical technique and HIPEC. Risks include infection, digestive issues, excessive bleeding and constipation.
- Cytoreductive Surgery & HIPEC: Surgical techniques known as debulking and cytoreductive surgery are used during a peritonectomy to remove as much tumor tissue as possible. Cytoreductive surgery is more extensive in that it attempts to remove all visible cancerous tissue, including removing the peritoneal lining. Doctors then pump a heated mixture of chemotherapy drugs directly into the abdominal cavity for up to two hours to allow it to reach all cancer cells not removed during surgery.
- Paracentesis: Doctors use a long hollow needle to draw out excess liquid from the abdomen, which relieves pressure on nearby organs and reduces symptoms. This is an outpatient procedure performed under local anesthesia. The procedure lessens symptoms, helps patients feel better and improves quality of life.
Pericardial and Testicular Mesothelioma Surgeries
Pericardial and testicular mesothelioma are the rarest forms of the cancer, accounting for less than 2% of cases combined. Surgeries for these conditions have varying success rates, and surgeries involving the heart tend to have higher risks of serious complications. Survival rates are higher among testicular patients compared to pericardial patients.
- Pericardiectomy: This surgery removes as much cancerous tissue as possible from the heart lining. It can relieve symptoms caused by pericarditis (inflammation of the pericardium) and pericardial effusion (buildup of fluid in the pericardium). It’s important to treat these conditions early because they can lead to deadly complications if untreated. Risks of the procedure include infection, heart complications and cardiac arrest.
- Pericardiocentesis: A pericardiocentesis is like thoracentesis and paracentesis. Except in this case, the fluids are removed from around the heart rather than the lungs or abdomen. It is used palliatively to improve quality of life and relieve symptoms. Risks include infection, abnormal heart rate and cardiac arrest.
- Orchiectomy: The most common treatment for testicular mesothelioma is inguinal orchiectomy, a surgery to remove one or both testicles along with the spermatic cord. 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.
Benefits and Risks of Surgery for Mesothelioma
Benefits of mesothelioma surgery include longer survival and improved symptoms. Pleural surgery reduces chest pain, improves breathing and cough. Peritoneal surgery improves abdominal pain and swelling plus digestive symptoms such as constipation. Robotic mesothelioma surgery benefits include reduced blood loss, pain and recovery time.
Risks of mesothelioma surgery include pain, numbness or burning, infection, excessive bleeding, cardiac complications and respiratory failure. Peritoneal surgery risks also include digestive issues, excessive bleeding and constipation.
Aggressive surgery can potentially remove mesothelioma completely. But there’s a risk that some cancer cells get left behind, which can grow and divide to later form new tumors. Chemotherapy is used in conjunction with surgery to eliminate many remaining cancer cells to prolong survival.
It’s important for surgical candidates to speak with their surgeon about the risks and benefits of different procedures. For example, a study published in 2014 reported a significantly higher mortality rate for patients who underwent the more radical EPP procedure compared to those who underwent the less invasive P/D procedure. The study reported a mortality rate of 10.5% for EPP and only 3.1% for P/D. Additionally, the morbidity rate, or complication rate, for EPP was 24.2%, whereas P/D had a morbidity rate of only 3.8%.
Mesothelioma Surgery Side Effects
The most common side effects of mesothelioma surgery are pain and swelling around the incision. This usually gets better over time, but it depends on the extent of the surgery.
- Bleeding: After chest surgery, some patients may cough up a small amount of blood. This usually disappears after a few days. Also, some patients may have a small amount of bleeding from the incisions.
- Cardiac Complications: Mesothelioma surgeries in the chest cavity pose the risk of cardiac complications. The most common risk is atrial fibrillation or cardiac arrhythmia (irregular or abnormal heartbeat).
- Dry Cough: A dry cough after lung surgery is caused by irritation of the remaining lung. Once the remaining lung recovers, your dry cough will disappear. This may take several weeks.
- Fatigue: Patients may feel fatigued from the stress of an invasive procedure. Fatigue may be intensified by not getting good nutrition and plenty of rest to restore the body’s energy levels.
- Infection: If you feel warm, flushed, chilled or dizzy, take your temperature with a thermometer. If you run a fever or have a port or catheter and notice redness, swelling, tenderness or pus around the wound, call your doctor.
- Pain After Surgery: Pain may come from your incision or may radiate toward your back or your belly. Alternatively, you may feel tingling, numbness, pins and needles, bloating or a sensation of electric shock.
- Pneumonia: The most common complication after major chest surgery is pneumonia. The best way to avoid pneumonia is to breathe deeply, cough up secretions and walk immediately after surgery.
If you have any questions about these or other symptoms or feel they are worse than they should be, call your doctor right away.
Recovering from Surgery
Each patient experiences a different recovery process depending on the surgery they had, their overall health and whether any complications arise. How long it takes to recover and the amount of pain you feel will depend on the extent of the surgery.
Your surgeon can help you develop a recovery and pain management plan to cope with the discomfort you experience after surgery. Before you leave the hospital, your doctor will provide a prescription for oral pain medication and your surgical team will provide guidance on the recovery process.
Some surgeries offer an easier recovery. After robotic surgery proved its effectiveness for other minimally invasive procedures, doctors began using it for chest cancer surgeries in 2006. In 2013, Dr. Farid Gharagozloo performed the first robotic extrapleural pneumonectomy for a pleural mesothelioma patient. Benefits of robotic surgery include reduced blood loss, less pain, reduced postoperative recovery time and less stress on the remaining lung after an EPP procedure.
The recovery process varies for people who undergo chemotherapy or radiation therapy after surgery. Doctors often tailor multimodal therapy plans around each patient’s health. Some patients may receive additional therapies soon after surgery, while other patients may require several weeks of recovery.
What to Do if You’re Considering Mesothelioma Surgery
The type of surgery your doctor recommends will depend on the stage of mesothelioma, cell type and the goal of the procedure. Mesothelioma surgeries, which are complex and not risk-free, can offer significant improvements in survival time, mesothelioma symptoms and quality of life.
- Talk to your surgeon to make sure you understand the risks and benefits of the procedure.
- Prepare for surgery based on the guidelines provided by your surgical team.
- Undergo surgery with one of the nation’s top mesothelioma surgeons.
- Plan for the recovery process by building a good support team at home.
- Talk to your doctors about follow-up appointments to see if surgery was successful.
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 appointments for imaging scans to observe the outcome of the surgery.
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 optimal therapies to combine with surgery.
Mesothelioma surgery can be a challenging and emotionally taxing experience for the patient and their loved ones. The recovery process may take weeks to months. Your loved one with mesothelioma may feel anxious, scared or overwhelmed about surgery. Caregivers, family and friends can provide emotional support, listen to concerns and offer encouragement and positivity. Remind them that they are not alone on this journey.
After surgery, the patient may need help with everyday tasks such as cooking, cleaning and running errands. Recovery from mesothelioma surgery can take time, and it is important to be patient and understanding. By offering this kind of support, you can help your loved one through this challenging time and boost their chances of a good recovery.