17 Min Read
Last Updated: 06/06/2024
Fact Checked

Written by Karen Selby, RN | Medically Reviewed By Dr. Jacques Fontaine | Edited By Walter Pacheco

Fact Checked

What Is Surgery for Malignant Mesothelioma?

Mesothelioma surgery includes procedures to diagnose the disease, remove cancer from your body or improve symptoms. Aggressive surgery in combination with chemotherapy and radiation is considered the best treatment for mesothelioma because it offers the greatest chance of long-term survival. The goal of surgery is to help you feel better and live longer. 

Patients may have several surgical options that vary depending on the type of mesothelioma malignancy, cancer stage and the goal of the procedure. Surgical options are available at all mesothelioma stages and typically are part of a multimodal treatment plan.

Key Facts About Mesothelioma Surgery
  • About 27.6% of pleural mesothelioma patients received surgery between 2004 and 2020, according to the National Cancer Database.
  • About half 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.

Your mesothelioma doctor will assess your overall health and determine if surgery, whether for tumor removal (cytoreductive) or for symptom relief (palliative), is right for you. Not all mesothelioma patients may be eligible for aggressive surgeries, but most patients qualify for palliative surgery.

These complex surgical procedures aren’t free from the risk of possible complications. However, advancements in care and cutting-edge technology at the nation’s top cancer centers offer patients significant improvements in survival time, symptom management and quality of life via mesothelioma surgery.

25%

Percentage of respondents to The Mesothelioma Center’s 2023 patient survey who had surgery and experienced remission.

Pleural Mesothelioma Surgery Options

The most aggressive surgeries for pleural mesothelioma include pleurectomy and decortication and extrapleural pneumonectomy. These surgeries may take several hours to complete, and recovery time varies depending on the procedure. Surgeons use more aggressive surgeries on people diagnosed in the early stages of mesothelioma. When deciding between pleurectomy and pneumonectomy, surgeons consider the patient’s unique medical needs and preferences. About 15% to 20% of patients with pleural mesothelioma qualify for such treatment for mesothelioma

There’s two categories of surgery we can offer pleural mesothelioma patients. 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.

Pleural mesothelioma has the most surgical options, though these procedures are less effective than surgeries for peritoneal mesothelioma patients. Specialists can match surgeries to best meet the patient’s needs and treatment goals.

Multimodal therapy combines major, tumor-removing surgery with other treatments, including radiotherapy and chemotherapy. This aggressive treatment approach can extend life expectancy.  

Extrapleural Pneumonectomy (EPP)

In this aggressive procedure, surgeons remove an entire lung, the lining around it and nearby lymph nodes. They also remove parts of the diaphragm and the lining around the heart, called the pericardium. 

“We go in between the ribs and remove the whole lining around the lung, the diaphragm, the lining between the heart and the lung, the whole lung and the lymph nodes,” says thoracic surgeon Dr. Jacques Fontaine.

Theoretically, EPP offers the best chance to remove all cancer cells for people with pleural mesothelioma. Benefits include improved symptoms and survival. However, it’s an intense procedure and permanently reduces the patient’s stamina and strength because an entire lung is removed, similar to a standard pneumonectomy. Other complications include abnormal heartbeat, blood clots and fluid buildup in the lungs. According to a 2024 report, 5-year overall survival after EPP ranges from 0% to 24%.

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. 

Did You Know?
A 2024 long-term survival analysis found the pleurectomy and decortication patient group had significantly higher 10-year overall survival rates at 16% than any other group.

A benefit to this procedure is patients keep 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 has a median overall survival of 13 to 29 months.

Continued Learning

Pleurectomy/Decortication (P/D)

Partial Pleurectomy (Debulking)

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. 

The partial pleurectomy involves opening the chest cavity and removing the outside of the pleural layer that lines the chest wall and lungs. It removes 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%.

Palliative Surgeries for Pleural Mesothelioma Patients

Patients not eligible for more aggressive mesothelioma treatment options may still benefit from palliative surgeries aimed to improve or maintain quality of life. The following procedures help control symptoms for people with late-stage pleural mesothelioma, and some people live longer thanks to these surgeries.

Pleurodesis

Pleurodesis drains fluid buildup between layers of the pleura. It may be 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. The talc in this procedure is sterile and asbestos-free.

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.

Thoracentesis

A doctor can drain pleural fluid through a hollow needle during a thoracentesis to relieve pressure and make it easier to breathe. Removing excess fluid around the lungs improves chest pain and shortness of breath. It reduces pressure on the chest and lungs and also offers more space for the lungs to expand.

Risks include pain at the incision site and infection. This is an outpatient procedure performed under local anesthesia. Part of the cancer diagnostic process may also involve testing the pleural fluid for cancer cells.

Survivor Story
Michael Cole Pleural Mesothelioma

Don’t Be Afraid of Aggressive Mesothelioma Treatment

Survivor Story

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.

Read Michael’s Story

Peritoneal Mesothelioma Surgery Options

The most effective and aggressive surgery for peritoneal mesothelioma is a peritonectomy with heated chemotherapy, known as HIPEC. Approximately half of peritoneal mesothelioma patients qualify for tumor-removing surgery. 

I think the best treatment for peritoneal mesothelioma is a combination of HIPEC or the hypothalamic interpersonal chemotherapy as well as what we call a cell reductive procedure. Which includes the peritonectomy procedure.

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 recent study published in Scientific Reports, patients with a low score respond best to surgery.

Paracentesis

During a paracentesis, doctors use a long, hollow needle to draw out excess liquid from the abdomen, which relieves pressure on nearby organs and reduces symptoms. The procedure lessens symptoms, helps patients feel better and improves quality of life.

Peritoneal mesothelioma patients frequently experience recurrent fluid buildup, prompting doctors to recommend using a continuous catheter instead of repeating drainage procedures. Catheter placement is an outpatient procedure performed under local anesthesia. Risks include infection and a persistent leak from the insertion site.

Peritonectomy Using Cytoreductive Surgery

During a peritonectomy, 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. Doctors use debulking and cytoreductive surgery techniques during a peritonectomy to remove as much tumor tissue as possible. They 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. 

Benefits include improved symptoms and longer survival when combining a peritonectomy with a cytoreductive surgical technique and HIPEC. Repeat HIPEC 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.

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Diagnostic Mesothelioma Surgical Procedures

Diagnostic mesothelioma surgical procedures play a pivotal role in confirming the type and stage of disease. Surgeons perform various procedures to obtain tissue samples for biopsy. These minimally invasive techniques involve inserting a camera and specialized instruments into the chest or abdominal cavity to view and extract suspicious tissue.

Laparoscopy

This minimally invasive surgical procedure is a valuable tool for obtaining tissue samples for biopsy and is the best for diagnosing peritoneal mesothelioma. It also helps doctors assess the extent of tumor spread within the abdominal cavity. 

Through tiny incisions in the abdomen, surgeons can use specialized tools to visualize and remove potentially cancerous tissue with greater precision. This leads to more accurate staging and tailored treatment plans.

Thoracoscopy 

Thoracoscopy, also called video-assisted thoracoscopic surgery, is a diagnostic procedure that 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.

It is the most accurate diagnostic test for pleural mesothelioma. After the procedure, a chest tube remains in place for about three days. It will be removed when your lung can fully expand without any leaks.

Pericardial and Testicular Mesothelioma Surgery

Surgeries for pericardial and testicular mesothelioma, the rarest forms of the disease, involve removing affected tissue or organs or draining fluid buildup. These procedures have varying success rates. 

The surgeries involving the heart tend to have higher risks of serious complications. Survival rates are higher among testicular patients compared to pericardial patients.

Orchiectomy 

The most common treatment for testicular mesothelioma is inguinal orchiectomy, a surgery to remove one or both testicles 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.

Pericardiectomy

A 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.

In pericardial mesothelioma patients, such symptoms are often the result of inflammation of the pericardium (pericarditis) and buildup of fluid(pericardial effusion).  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

Pericardiocentesis is like 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.

Palliative use 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 the procedure, you should contact your doctor if draining from the incision increases or you notice chest pain or severe symptoms.

Surgical patients who reach out to us have a lot of questions and are very concerned about quality of life post surgery. We offer information and can connect them with a mesothelioma specialist for a second opinion about their treatment.

Benefits of Mesothelioma Surgery

Benefits of mesothelioma surgery 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.

Benefits of Surgery
  • Advancements in Surgical Techniques: Advances in surgical techniques, such as minimally invasive surgery and robotic surgery, have improved outcomes and reduced postoperative complications. Minimally invasive surgery results in shorter hospital stays and lower rates of complications.
  • Extended Survival Rates: Mesothelioma surgery can extend survival significantly when performed at an early stage. 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.
  • Improved Quality of Life: Surgery can alleviate symptoms such as chest pain, difficulty breathing and fluid buildup in the chest cavity.
  • Long-Term Survival Potential: Although mesothelioma is often considered a terminal illness, surgery offers the potential for long-term survival in select cases. About 24% of patients with early-stage mesothelioma live at least five years, and most of these patients undergo multimodal treatment with surgery.

Dr. Farid Gharagozloo performed the first robotic surgery for a pleural mesothelioma patient in 2013. Today, robotics are used in mesothelioma surgeries across the country. 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.

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.

Risks and Possible Mesothelioma Surgery Complications

The most common complications 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.

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.

Mesothelioma Surgery Complications
  • Bleeding: After chest surgery, some patients may cough up a small amount of blood. This usually disappears after a few days. Some patients may also 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 usually the result of 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’re running 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.

Aggressive surgery can potentially remove mesothelioma completely. However, there’s a risk that some cancer cells left behind can grow and divide to form new tumors. Chemotherapy is used in conjunction with surgery to eliminate 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. If you have any questions about complications or feel any effects are worse than they should be, call your doctor right away. Addressing complications quickly is important throughout the recovery process. 

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Mesothelioma Surgery Recovery

Each patient has a different mesothelioma surgery 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 your procedure. 

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, you’ll get a prescription for oral pain medication and more information about the recovery process.

With EPP, for example, it’s a tough recuperation. It can take 3 to 6 months.

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. 

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. Patients should be careful to follow any instructions and attend all medical appointments to help their recovery.

Common Questions About Surgery for Mesothelioma

What should I do if I’m considering mesothelioma surgery?

Talk to your surgeon to make sure you understand the risks and benefits of the procedure. You should prepare for surgery based on the guidelines your surgical team provides. Planning for the recovery process involves building a good support team at home. Talk to your doctors about follow-up appointments to see if surgery was successful.

How will I know if I’m eligible for mesothelioma surgery?

You can book a surgical consultation with a thoracic surgeon to learn about your eligibility. They’ll review your medical records, imaging scans and pathology report to determine if surgery is appropriate.

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.

Will I need additional treatments such as chemotherapy or radiation therapy following surgery?

Doctors may recommend chemotherapy to kill any remaining cancer cells after surgery and radiation to prevent local recurrence. These treatments improve the chance of long-term survival in combination with surgery.

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