Treating Mesothelioma with Surgery
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 patients also have several surgical options that vary depending on the type of mesothelioma, cancer stage and goal of the procedure.
But not all mesothelioma patients may be eligible for surgery. 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.
Important Factors for Determining Surgery Eligibility
- Your overall health is good.
- Your lung and heart function tests indicate normal or near-normal organ function.
- Your doctor is confident you can recover from potential surgery complications.
- Your mesothelioma has not spread too far.
- Your mesothelioma is not of the sarcomatoid cell type.
Mesothelioma surgery is neither curative nor risk-free, but it offers significant potential improvements in survival time 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
Surgeries for mesothelioma patients generally fall into three categories:
- Palliative care
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 Mesothelioma Surgery
Typically, your medical team cannot make a definitive and accurate cancer diagnosis without direct access to your tumor.
Biopsies obtain a sample of cancer cells for examination. The cells can be studied to confirm mesothelioma and determine the mesothelioma cell type. Diagnosis requires a pathologist with extensive experience dealing with mesothelioma.
Mesothelioma Cytoreductive Surgery
This aggressive treatment approach can extend life expectancy and potentially send mesothelioma into remission. Remission isn’t a cure, but it provides time for patients to live without having to cope with active cancer in their body.
This is a less invasive alternative to tumor-removing surgery. The aim of all palliative treatments is to improve quality of life by alleviating pain and other cancer symptoms. Some patients experience longer life with palliative surgery, too.
If you qualify for surgery, you also may be able to join a cancer 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.
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.
Diagnosing Pleural Mesothelioma and Easing Symptoms
The primary diagnostic procedure for pleural mesothelioma is a thoracoscopy. The two main palliative procedures, thoracentesis and pleurodesis, also can be used for diagnosis.
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.
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. 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 2-3 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.
This procedure is similar to thoracentesis and is used to drain fluid buildup between layers of the pleura. A surgeon may use a chemical, usually talc, that causes the lung to stick to the chest wall, decreasing the likelihood of the pleural fluid returning.
I had gotten to the point where I couldn’t walk without being out of breath. It scared the heck out of me. But having my lung drained was immediate relief. I felt so much better.Mary LyonsPleural mesothelioma survivor diagnosed in 2015
Removing Pleural Mesothelioma Tumors
There are two different types of cytoreductive surgeries: Extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). Around 15% to 20% of patients with pleural mesothelioma qualify for tumor-removing surgery.
The difference between the two surgical procedures is that EPP carries greater risks and has a larger impact on quality of life.
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. However, it is an intense procedure and permanently reduces the patient’s stamina and strength.
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.
Pleurectomy and Decortication: A Firsthand Experience
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.
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.
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 cancer stage during the procedure. This helps guide the treatment plan. If cancer is localized, they will proceed with tumor removal.
The average hospital stay after a thoracotomy is five to 10 days.
What to Expect After Thoracotomy
- Pain, Numbness, Burning: Surgery irritates nerve endings near the incision, and you may experience pain, numbness or burning below your breast and at the front of your rib cage.
- Fluid Drainage: Clear or pink fluid may drain from the incision. This is normal.
- Incision Care: You will be given instructions on caring for your incision such as not submerging it in a bathtub or spa for several weeks.
- Taking It Easy: You will need to avoid heavy lifting and other strenuous activities for at least eight weeks, and maybe longer if your doctor feels it’s necessary for proper recovery.
- Rehabilitation: Your doctor will refer you to a physical therapist or pulmonary rehab specialist to give you a program of daily breathing exercises and to improve your strength, circulation and lung capacity.
Robotic Surgery for Pleural Mesothelioma
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
- Reduced blood loss
- Less pain
- Reduced postoperative recovery time
- Less stress on the remaining lung after EPP
Top Pleural Mesothelioma Surgeons
Peritoneal Mesothelioma Surgery
Peritoneal mesothelioma accounts for less than 20% of all mesothelioma cases. If untreated, it is more aggressive than the other types of mesothelioma, with a six-month average survival.
However, peritoneal disease also responds better to treatment than most other mesothelioma cancers. With the combination of surgery and hyperthermic intraperitoneal chemotherapy (HIPEC), nearly half of patients live five years after diagnosis.
Diagnosing Peritoneal Mesothelioma and Easing Symptoms
When mesothelioma occurs in the abdomen, it can cause fluid buildup in the peritoneal cavity. This is the space between the two membranes that separate the abdominal organs from the abdominal wall.
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 in two ways:
- Palliative care: This 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.
- Diagnostic: If doctors don’t know the cause of fluid accumulation, they can 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.
Peritoneal fluid buildup is also known as ascites or peritoneal effusion, and paracentesis is sometimes called an abdominal tap or an ascitic tap.
Removing Peritoneal Mesothelioma Tumors
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.
In this procedure, surgeons remove the diseased parts of the peritoneal lining of the abdomen. They use cytoreductive surgery to remove as much cancerous growth as possible from the abdominal cavity.
This is also called debulking surgery, and it may involve removing parts of the liver, pancreas, spleen, gall bladder, bowels and stomach, too.
Mesothelioma specialists pump a heated mixture of chemotherapy drugs directly into the abdominal cavity during surgery, after debulking. 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.
Top Peritoneal Mesothelioma Surgeons
Pericardial Mesothelioma Surgery
Pericardial mesothelioma patients may experience chest pain, dyspnea (shortness of breath) and coughing. These symptoms are the result of fluid buildup in the heart lining.
A pericardiocentesis is similar to 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.
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.
I want to make it through another surgery and reach the 10-year mark. My future is going to be happy, and every day will be an adventure.Isabel De La CamaraPeritoneal mesothelioma survivor diagnosed in 2008
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.
Testicular Mesothelioma Surgery
Testicular mesothelioma is rare and occurs in less than 5% of cases, making diagnosis difficult. Also known as mesothelioma of the tunica vaginalis testis, there are no symptoms unique to the disease. The most common symptom is hydrocele, a buildup of fluid in the scrotum. About a third of patients tend to have a painless scrotal mass.
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 conducts the surgery.
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.
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.
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.
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. Once the inflammation in your chest has gone down, you are no longer at risk of atrial fibrillation.
The most common complication after major chest surgery is a pneumonia. Developing pneumonia after major chest surgery is a serious complication and could be fatal. The best way to avoid a 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.
A dry cough after lung surgery is a common side effect. It is due to 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.
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.
If you have any questions about these or other symptoms or feel they are worse than they should be, call your doctor right away.
Excessive inflammation, redness, severe incision pain or foul-smelling drainage at the surgery site may be signs of infection. It is imperative to report infection immediately to prevent it from becoming fatal. Postoperative infection must be treated under a doctor’s care.
Pain After Surgery
Each patient experiences pain differently.
The amount of pain you may feel will also depend on the extent of the surgery. The 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 sensation or a sensation of electric shock.
Your surgeon can help you develop a 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.
Mesothelioma surgery is tricky for two reasons: First, the surgeon must know which patients will truly benefit from surgery and which will not. Second, mesothelioma surgery is a long and complex operation with many potential dangers and pitfalls. It’s important that a surgeon be experienced enough to avoid those pitfalls.
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.
- Who are the top mesothelioma surgeons?
Dr. Paul H. Sugarbaker is the world’s leading expert on peritoneal mesothelioma. He worked to develop the surgical techniques used today at most mesothelioma specialty centers.
Dr. Abraham Lebenthal was trained by Dr. David Sugarbaker, the father of modern mesothelioma treatment. Lebenthal is also a professor at Harvard Medical School and has extensive experience in all types of mesothelioma surgeries and treatments.
Dr. Raja Flores is the chairman of the thoracic surgery department at Mount Sinai Medical Center in New York City and has also trained under Dr. David Sugarbaker. He has worked with hundreds of patients diagnosed with mesothelioma after the 9/11 terrorist attack at the World Trade Center in 2001.
- How can I find out if I qualify for mesothelioma surgery?
A patient is likely to qualify for mesothelioma surgery if they are generally in good health, and cancer has not spread beyond one lung. Approximately 20% of pleural mesothelioma patients and 40% of peritoneal mesothelioma patients qualify for surgery.
A doctor will determine if a patient is eligible for surgery based on the patient’s medical history, histology (cancer cell type), cancer stage and history of previous treatments.
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