Mesothelioma Surgery

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. Major 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 goal of the procedure.

The most common aggressive surgeries for mesothelioma include pleurectomy/decortication, extrapleural pneumonectomy and peritonectomy with HIPEC or heated chemotherapy. These surgeries may take several hours to complete, and recovery time varies depending on the procedure.

Eligibility for Surgery

Not all mesothelioma patients may be eligible for aggressive surgery, but most patients qualify for surgeries that improve symptoms and quality of life. Before surgery, mesothelioma doctors assess each patient to make sure they are healthy enough to undergo surgery. Doctors examine lung and heart health with pulmonary function and cardiac stress tests.

It is important to speak with a surgical specialist to determine if you meet the eligibility criteria. Different surgical options are available at all mesothelioma stages.

Surgical Consultations

Eligibility for surgery is thoroughly vetted in a surgical consultation, where the surgeon and the surgical team review a patient’s medical history, imaging scans and biopsy results. The team closely analyzes this information to ensure they select qualified patients who will benefit from the procedure and exclude patients who are at high risk of suffering complications.

Surgical consultations allow patients to meet with the surgeon and his or her team to discuss everything about the procedure, including preparation and recovery. Patients may ask questions, raise concerns and inquire about the surgeon’s success rate. These consultations may take place in person or virtually through video conferencing.

Mesothelioma surgery is neither curative nor risk-free, but it offers significant potential improvements in survival time, mesothelioma symptoms and quality of life. These procedures are complex and performed at the nation’s top cancer centers that feature the latest technologies such as robotic surgery.

Types of Mesothelioma Surgery

You and your mesothelioma medical team can work together to choose the type of mesothelioma surgery that is best for you.

Doctors will base their decisions on your overall health, the results of your imaging scans and prior biopsies, goal of the procedure and stage of your mesothelioma.

Diagnostic Surgery

Your medical team will use minimally invasive surgeries to make a definitive and accurate cancer diagnosis. Known as biopsies, these procedures obtain a sample of cancer cells for examination. The cells can be studied to confirm mesothelioma and determine the mesothelioma cell type. 

Diagnostic surgeries include thoracentesis, thoracoscopy and paracentesis. The majority of mesothelioma patients qualify for these procedures because they are minimally invasive and the risk of complications is low.

Tumor-Removing Surgery

Aggressive surgeries that aim to remove as many tumors as possible offer the greatest chance of long-term survival for people with mesothelioma. These surgeries include pleurectomy/decortication, extrapleural pneumonectomy and peritonectomy with debulking or cytoreductive surgical techniques.

Debulking and cytoreductive surgical techniques aim to remove as much tumor tissue as possible, which may involve removing an entire lung or the lining of the lungs or abdomen. Patients who qualify for aggressive surgeries tend to be in overall good health aside from their cancer diagnosis. 

Palliative Surgery

The aim of all palliative treatments is to improve quality of life by alleviating pain and other cancer symptoms. Palliative surgeries are less invasive alternatives to tumor-removing surgery.  Some patients experience longer life with palliative surgery, too. Examples of palliative surgeries include thoracoscopy, pleurodesis and paracentesis.

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. This research is slowly improving mesothelioma survival rates.

Top Mesothelioma Surgeons

Pleural Mesothelioma Surgery

Pleural mesothelioma, which occurs in the pleural membrane lining the chest cavity and enclosing the lungs, has the most surgical options. Because pleural disease accounts for roughly 70% to 75% of all mesothelioma cases, there is more research on it than other types.

The research has led to the development of a variety of pleural mesothelioma surgery types. These procedures can be matched to best meet patient needs and treatment goals. Around 15% to 20% of patients with pleural mesothelioma qualify for aggressive tumor-removing surgery.

Combining major, tumor-removing surgery with other treatments, such as radiotherapy for mesothelioma and chemotherapy, is called multimodal therapy. This aggressive treatment approach can extend life expectancy and potentially send mesothelioma into remission. 

Extrapleural Pneumonectomy (EPP)

This aggressive surgery removes an entire lung, the lining around it, nearby lymph nodes and parts of the diaphragm and the lining around the heart called the pericardium.

Theoretically, EPP offers the best chance to remove all cancer cells. Benefits include improved symptoms and survival. However, it is an intense procedure and permanently reduces the patient’s stamina and strength.

Pleurectomy/Decortication (P/D)

The P/D was developed as a less aggressive alternative to removing an entire lung. 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 partial pleurectomy, sometimes called debulking, aims to remove as much tumor tissue as possible when the tumor cannot be completely removed.

The procedure may take hours to complete depending on the severity of disease and whether any complications arise. A benefit to this procedure is keeping the affected lung. Risks include infection, excessive bleeding.

“Dr. David Sugarbaker performed my pleurectomy and decortication surgery in 2012 at Brigham and Women’s Hospital in Boston. The surgery took six hours. It was intense, and the recovery was rough, but I survived. From that point on, I’ve looked at every day as a gift.”

Emily Ward

Pleural Mesothelioma Survivor

Pneumonectomy

This procedure involves removing a lung. A patient may qualify for this surgery if the cancer hasn’t spread beyond one lung. Most mesothelioma surgeons perform the more extensive EPP surgery rather than simple pneumonectomy.

However, one 2019 study found less invasive mesothelioma surgery resulted in better survival for some patients with early disease.

Thoracotomy

Surgery for EPP, P/D, pneumonectomy, lobectomy, wedge resection and segmentectomy all begin with thoracotomy. A thoracotomy, the first step for many asbestos-related lung cancer surgeries, is used to make an incision on either side of the chest.

During surgery, the surgeon may discover the tumor is too extensive to remove. They can still gather information on the cancer stage during the procedure. This helps guide the treatment plan. If cancer is localized, they will proceed with tumor removal to improve symptoms and extend survival. The average hospital stay after a thoracotomy is five to 10 days. Risks include irritated nerve endings near the incision, pain, numbness or burning below your breast and at the front of your rib cage.

Pleurodesis

This procedure is like thoracentesis and 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.

Thoracoscopy

A thoracoscopy is also called video-assisted thoracoscopic surgery (VATS). This diagnostic procedure, performed under general anesthesia, involves inserting a small camera and a long, thin probe through small incisions between the ribs.

These tools enable a surgeon to take biopsy samples from the tissue around the lungs without opening the entire chest cavity. The video component allows the surgeon to see the extent of the disease and exactly where to retrieve the best biopsies.

Thoracentesis

When fluid builds up between the two layers of the pleural lining surrounding the lungs, they cannot fully expand, which causes shortness of breath and discomfort. A doctor can drain this fluid through a hollow needle to relieve pressure and make it easier to breathe. Risks include pain in the incision 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

Placement of a small silicone catheter, called a PleurX, allows the patient to drain the 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. 

Once the fluid has completely dried and the catheter is no longer draining, it may be removed. It usually takes several weeks for the fluid to dry up. Benefits include reduced chest pain and improved breathing. Risks include infection and pain where the catheter is placed.

Peritoneal Mesothelioma Surgery

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 heated chemotherapy also known as HIPEC. Risks include infection, digestive issues, excessive bleeding and constipation.

Cytoreductive and Debulking Surgical Techniques 

Surgical techniques known as debulking and cytoreductive surgery are used during a peritonectomy to remove as much tumor tissue as possible. Debulking refers to removing as much of a tumor as possible when it cannot be completely removed. Cytoreductive surgery is more extensive in that it attempts to remove all visible cancerous tissue including removing the peritoneal lining that often contains many small tumors in the case of peritoneal mesothelioma.

Mesothelioma specialists also pump a heated mixture of chemotherapy drugs directly into the abdominal cavity during surgery, after debulking and cytoreduction. It may remain in the abdomen for up to two hours to allow it to reach all cancer cells not removed during surgery.

HIPEC has fewer side effects than oral or intravenous chemotherapy. Because it isn’t injected into the bloodstream, much stronger drugs can be used. Some chemotherapy does reach the bloodstream, but HIPEC causes less severe side effects than intravenous chemotherapy.

Paracentesis

When fluids build up in the abdomen, doctors can drain it with a minor surgical procedure called paracentesis. They use a long hollow needle to draw out the excess liquid, which relieves pressure on nearby organs and reduces symptoms. This is an outpatient procedure performed under local anesthesia. 

Paracentesis is used to diagnose and treat peritoneal mesothelioma. If doctors don’t know the cause of fluid accumulation, they use a paracentesis to examine the fluids for the presence of cancer cells. This can help them diagnose peritoneal mesothelioma or rule it out if another condition is causing the problem.

The procedure lessens symptoms, helps patients feel better and improves quality of life. Repeated therapeutic paracentesis procedures can be administered as palliative care for patients with advanced stages of this disease. Alternatively, a PleurX catheter can be placed, so that patients can drain the fluid at home. Peritoneal fluid buildup is also known as ascites or peritoneal effusion, and paracentesis is sometimes called an abdominal tap or an ascitic tap.

Omentectomy

An omentectomy surgically removes the omentum, which is a thin fold of fatty abdominal tissue that covers the stomach, large intestine and other organs in the abdomen. The omentum contains blood vessels, lymph vessels and lymph nodes that may become invaded by peritoneal mesothelioma tumors.

An omentectomy is commonly included in a peritonectomy procedure if the surgeon suspects cancer may have spread to the omentum.

Surgery for Pericardial and Testicular Mesothelioma

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

The tumor-removing procedure to treat pericardial mesothelioma is a 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.

Heart surgeons, also called cardiac surgeons, perform pericardiectomies. Patients should ask how many of these procedures a surgeon has performed to gauge their experience level. Surgeons who have performed more pericardiectomies tend to have the best outcomes and fewer patient complications. And some hospitals are known for having experts who do these rare surgeries more often.

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.

Pericardial fluid rarely contains malignant cells when mesothelioma is present, so the procedure is not effective for diagnosing disease. It is used palliatively to improve quality of life and relieve symptoms. Risks include infection, abnormal heart rate and cardiac arrest.

Orchiectomy

After confirmation with a biopsy, 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. This procedure sometimes occurs when a non-specialist operates to remove a hernia and realizes it’s a tumor that requires an inguinal orchiectomy.

The surgeon may also perform a lymphadenectomy to remove nearby affected lymph nodes.

Testicular mesothelioma is an aggressive type of cancer and can spread rapidly outside the testicle, which may make a patient ineligible for surgery. Chemotherapy and radiation can also complement the procedure to kill cancer cells remaining after surgery.

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 or oozing from the wounds. If there is more than just mild oozing, seek immediate medical attention.

Fatigue

Even after anesthesia wears off, patients may feel fatigued from the stress of an invasive procedure. This is especially true after a major operation such as EPP or P/D. Fatigue may be intensified by not getting good nutrition and plenty of rest to restore the body’s energy levels.

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). This is not a heart attack. Instead, it’s an irritation of the heart from performing chest surgery. Your doctor may give you medication to regain regular heart rhythm. 

Pneumonia

The most common complication after major chest surgery is pneumonia. Developing pneumonia after major chest surgery is a serious complication and could be fatal. The best way to avoid pneumonia is to breathe deep, cough up secretions and walk immediately after surgery. It is also very important to continue walking and staying active once you return home from the hospital.

Dry Cough

A dry cough after lung surgery is caused by irritation of the remaining lung, which is trying to re-expand to take over the space and function of the portion of lung that was removed. Once the remaining lung has finished expanding, your dry cough will disappear. This may take several weeks. If the cough is not dry or if you are coughing up blood or thick mucus, this may be pneumonia, and you should contact your doctor.

Infection

Excessive inflammation, redness, or foul-smelling drainage at the surgery site may be signs of a wound infection. If you suspect an infection, please contact your doctor immediately.

Pain After Surgery

Pain may come from your incision or may radiate toward your back or your belly. This is due to inflammation of the nerves that run on the undersurface of every rib. Alternatively, you may feel tingling, numbness, pins and needles, bloating or a sensation of electric shock. 

If you have any questions about these or other symptoms or feel they are worse than they should be, call your doctor right away.

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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 may 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.

How Robotic Surgery Shortens 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. Gharagozloo currently consults with and treats mesothelioma patients at Florida Hospital Celebration Health. He says the robotic da Vinci Surgical System he uses will change the future of mesothelioma treatment.

Surgeons use tiny, computer-guided instruments attached to a robotic arm for more precise movement, a magnified view and better maneuverability during the operation. 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.

Watch: Thoracic surgeon Dr. Farid Gharagozloo explains the advantages of robotic surgery for mesothelioma patients.

Common Questions About Mesothelioma Surgery

Can Mesothelioma be removed with surgery?

Aggressive surgery can potentially remove mesothelioma completely. However, some cancer cells are often left behind which can grow and divide to later form new tumors.

Chemotherapy is used in conjunction with surgery to eliminate the majority of remaining cancer cells and prolong survival.

How effective is surgery as a treatment for mesothelioma?

Surgery is effective for removing large tumor mass and preventing the spread of 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.

Mesothelioma surgeries are intensive procedures, but they offer the best chances of improving a patient’s prognosis.

What are the most common surgeries for mesothelioma?

The most common surgeries for pleural mesothelioma include pleurectomy/decortication, extrapleural pneumonectomy, thoracoscopy, thoracentesis, pleurodesis and PleurX catheter placement. The most common surgeries for peritoneal mesothelioma include paracentesis and peritonectomy, and the latter is often combined with heated chemotherapy and cytoreductive surgical techniques.