Surgery for mesothelioma can include pleurectomy/decortication (P/D) and extrapleural pneumonectomy (EPP). P/D removes all diseased tissue around the lung, while EPP removes the lung as well. Patients must be in strong health with limited cancer spread to benefit from major surgery.
Major surgery offers the greatest chance of long-term survival with mesothelioma. If an experienced surgeon can remove all visible signs of the cancer before it spreads to distant areas of the body through metastasis, you could live for many years after surgery.
Before discussing surgery as an option, doctors will want to make sure your body is strong enough to endure a major procedure and recover from it. They will determine your lung and heart health by conducting a pulmonary function test and running cardiac tests such as an electrocardiogram (EKG), stress test, echocardiogram or coronary angiogram.
If your overall health is strong enough to withstand potential complications from surgery, and your mesothelioma has not spread too far, then your doctor will approve you as a candidate for surgery. There are risks involved in surgery, but the potential rewards are great. Many of the survivors on our Wall of Hope opted for surgeries that gave them more years to spend with children and grandchildren.
Three Different Purposes of Mesothelioma Surgery
Surgeries for mesothelioma patients generally fall into three categories: Diagnostic, tumor removal and palliative. Sometimes when major surgery is not an option, a patient can still benefit from a less invasive procedure. Choosing what type of mesothelioma surgery to have is up to you and the specialists overseeing your care.
Statistics support surgery as the best first-line treatment option for living longer with this disease. When it comes to each individual case, sometimes the choice is clear-cut, and sometimes the patient’s circumstances make it difficult to balance the risk and the reward.
A mesothelioma specialist can conduct a thorough assessment and explain what procedures make the most sense for your situation. They will take several factors into account, including the stage of the cancer and your overall health.
Diagnostic
A medical team usually cannot make a definitive cancer diagnosis without performing a minor surgery called a biopsy to extract a sample of cancer cells for examination.
Tumor Removal
When performed as part of multimodal therapy, major surgery to remove tumors can extend life expectancy and potentially even send mesothelioma into remission.
Palliative
Palliative surgery is a less invasive alternative to tumor-removing surgery, and it aims to improve quality of life by alleviating pain and other cancer symptoms.
If you qualify for surgery, you may also be able to participate in a clinical trial of an experimental treatment. Mesothelioma surgeons can offer their patients the opportunity to participate in clinical trials to investigate the best therapies to combine with surgery, and this research is slowly improving mesothelioma survival rates.
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Surgical treatment for pleural mesothelioma has made great strides since the first major procedures for this disease were pioneered in the 1970s. However, the rarity of this asbestos-related cancer means that most patients still need to travel to a specialty cancer center to receive treatment from a mesothelioma specialist.
Diagnosing Pleural Mesothelioma and Easing Symptoms
The primary diagnostic procedure for pleural mesothelioma is a thoracoscopy, though the two main palliative procedures, thoracentesis and pleurodesis, can also be used for diagnosis.
Thoracoscopy
Also called video-assisted thoracoscopic surgery (VATS), this procedure involves inserting a special camera and a long, thin probe through small incisions in the chest. These tools enable a doctor to take a biopsy sample from the tissue around the lungs without having to open the entire chest cavity.
When fluid builds between the two layers of the pleural lining surrounding the lungs, a doctor can drain it through a hollow needle to relieve pressure and make it easier to breathe. The pleural fluid can then be tested for cancer cells as part of the diagnostic process.
This procedure drains fluid buildup, similar to a thoracentesis, but then goes a step further by sealing the area to prevent fluid from building again in the future. Doctors usually inject talc into the pleural cavity to seal it, although chemicals, instead of talc, may be used in certain cases.
“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 Lyons, pleural mesothelioma survivor diagnosed in 2015
Doctors primarily use two different tumor-removing surgeries for pleural mesothelioma: Extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). Around 15 to 20 percent of people with pleural mesothelioma qualify for tumor-removing surgery.
“Thoracotomy” is a general term for a surgery that allows doctors to access a patient’s lungs, heart, aorta, trachea or diaphragm, and it involves making an incision 4–10 inches long on either side of the chest. Extensive procedures, such as EPP and P/D, require a thoracotomy. They are also the first steps in several asbestos-related lung cancer surgeries such as pneumonectomy, lobectomy, wedge resection and segmentectomy.
Unfortunately, up to 25 percent of mesothelioma patients cleared for surgery are found to be inoperable after a thoracotomy is performed. Even with the latest advances in imaging technology and other diagnostic techniques, surgeons cannot determine whether a planned tumor-removing surgery is actually possible until they directly view the patient’s lungs and how far the cancer has spread.
In cases where the cancer has spread too far for tumor-removing surgery to be of any use, the surgeons will still use the opportunity to take tumor samples and make observations to pinpoint the cancer stage and guide the patient’s overall treatment plan. If the cancer is localized, however, the surgeons will proceed with the tumor removal.
Pneumonectomy
This procedure involves removing a lung. A patient may qualify for this surgery if the cancer hasn’t spread beyond one lung, but today most mesothelioma surgeons perform the more extensive EPP surgery rather than just a pneumonectomy.
This aggressive surgery involves the removal of an entire lung, the lining around it, nearby lymph nodes and parts of the pericardium and diaphragm. Theoretically, it offers the best chance to remove all cancer cells, but it also permanently reduces the patient’s stamina.
This procedure was developed as a less aggressive alternative to removing a lung. Surgeons remove the pleural lining around the lungs and all visible tumors, scraping the diseased lung rather than removing it.
The average hospital stay after a thoracotomy is five to 10 days. Because of irritation to nerve endings near the incision, you will likely experience pain, numbness or burning below your breast and at the front of your rib cage.
Drainage of clear or pink fluid from the incision is normal. You should clean your incision in the shower, washing gently with warm water and a mild soap. Avoid submerging the incision in a bathtub or spa for three weeks. Avoid heavy lifting and other strenuous activities for eight weeks, because they could put stress on your incision and delay recovery. During recovery, you should perform breathing exercises and walk every day to help improve your strength, circulation and lung capacity.
Robotic Surgery for Pleural Mesothelioma
Robotic thoracic surgeon Dr. Farid Gharagozloo explains the advantages of robotic surgery for mesothelioma patients.
Robotic surgery is the newest way for thoracic surgeons to conduct cancer surgeries. After the technology proved its effectiveness for minimally invasive procedures, doctors began using it for chest cancer surgeries in 2006. Then, in 2013, Dr. Farid Gharagozloo performed the first major robotic surgery for a pleural mesothelioma patient, using the technique to perform an extrapleural pneumonectomy.
Gharagozloo, currently practicing at Florida Hospital Celebration Health, says the da Vinci Surgical System he uses will change the future of mesothelioma treatment. Using a computer board, surgeons can guide tiny instruments attached to a robotic arm, allowing for more precise movement, a more magnified view and better maneuverability during the operation.
Robotic surgery also significantly reduces blood loss, shortening postoperative recovery time and lowering the stress on the remaining lung after an EPP, which is often a major problem when the surgery is done conventionally.
Former director of Allegheny Hospital’s Esophageal and Lung Institute.
Also directed the University of Pittsburgh’s Lung Cancer Program.
Opened his specialized practice in 2015.
Peritoneal Mesothelioma Surgery
Peritoneal mesothelioma accounts for less than a quarter of all mesothelioma cases, making it an uncommon variant of an already rare cancer. Left untreated, it is also more aggressivethan the other types of mesothelioma, and it wasn’t long ago that nearly everyone diagnosed with peritoneal mesothelioma survived only six months on average.
Today, however, peritoneal mesothelioma patients can benefit from one of the greatest modern advancements in mesothelioma treatment: The HIPEC procedure. Nearly half of peritoneal patients treated with this special combination of surgery and chemotherapy live beyond five years.
Diagnosing Peritoneal Mesothelioma and Easing Symptoms
A paracentesis is a minor surgical procedure that can serve a diagnostic or palliative purpose. When fluid builds up in the peritoneal cavity — the space between the two membranes that separate the abdominal organs from the abdominal wall — the fluid can be drained through a hollow needle to relieve pressure on nearby organs. Peritoneal fluid buildup is also known as ascites, and this procedure is sometimes called an abdominal tap or an ascitic tap.
Doctors can examine ascitic fluid to confirm a diagnosis of peritoneal mesothelioma. Because ascites often reoccurs with peritoneal mesothelioma, repeated therapeutic paracentesis procedures can be administered as palliative care for patients with advanced stages of this disease.
Removing Peritoneal Mesothelioma Tumors
Nearly 40 percent of peritoneal mesothelioma patients qualify for tumor-removing surgery. The most effective treatment for this disease combines a peritonectomy with a HIPEC procedure.
Peritonectomy
In this procedure, surgeons remove the diseased parts of the peritoneal lining of the abdomen and then perform 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.
Hyperthermic intraperitoneal chemotherapy (HIPEC) is administered immediately after the debulking phase of the peritonectomy. Mesothelioma specialists pump a heated mixture of chemotherapy drugs directly into the abdominal cavity and leave it there for several hours so it can be absorbed by any remaining cancer cells.
HIPEC has fewer side effects than oral or intravenous chemotherapy because the drugs are not injected directly into the bloodstream. Targeting chemotherapy in this way allows doctors to use much stronger drugs against the cancer. Some of the chemotherapy used does get absorbed into the bloodstream, but again this causes less severe side effects than does intravenous chemotherapy.
Expertise in the use of hyperthermic intraperitoneal chemotherapy (HIPEC).
Came to Moores from the University of Pittsburgh School of Medicine.
“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 Camara, peritoneal mesothelioma survivor diagnosed in 2008
Pericardial Mesothelioma Surgery
Pericardial mesothelioma patients may experience chest pain, dyspnea (shortness of breath) and coughing because of a buildup of fluid in the heart lining. A pericardiocentesis is a palliative procedure that can effectively remove fluid buildup to relieve these symptoms.
Unfortunately, pericardial fluid rarely contains malignant cells when mesothelioma is present, making this procedure ineffective for diagnosis.
The tumor-removing surgery available for pericardial mesothelioma is a pericardiectomy, in which a surgeon 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, before they cause deadly complications.
Heart surgeons, also known as cardiac surgeons, perform pericardiectomies. Patients should ask how many of these procedures a surgeon has performed to gauge the experience level of the physician.
Certain hospitals perform more of these surgeries than others. For example, surgeons at Cleveland Clinic follow the guidance of Dr. Allan Klein, director of the hospital’s Center for the Diagnosis and Treatment of Pericardial Diseases.
Meanwhile, Dr. Jae K. Oh, the director of Cardiac Imaging and the Pericardial Disease Clinic at Mayo Clinic in Rochester, is instrumental in pericardial mesothelioma surgeries performed there.
Mesothelioma Surgery Side Effects
The most common side effects of mesothelioma surgery are pain, swelling or infection at the incision site. Whenever a foreign object, such as a needle, knife or tube, is placed into the body, swelling and drainage usually occur. In fact, open drainage is recommended during the healing process.
Mild swelling, draining and bruising of the injured tissues are typical and will usually resolve themselves on their own within a few days or weeks.
Other side effects of surgery include:
Bleeding
Most patients will experience minimal bleeding that poses no threat to overall health, and the body will be able to regenerate any blood that has been lost. During recovery, overstretching or otherwise damaging the incision area can result in bleeding. If bleeding becomes extensive, seek immediate medical attention.
Fatigue
Even after anesthesia wears off, patients may still feel fatigued from the basic bodily stress that occurs with an invasive procedure, especially a major operation such as EPP or P/D. The fatigue may be intensified if the patient does not eat enough food or get enough rest to restore the body’s energy levels.
Cardiac complications
Mesothelioma surgeries performed in the chest cavity pose the risk of causing cardiac complications. The most common risk is atrial fibrillation or cardiac arrhythmia (irregular or abnormal heart beat).
Dr. Fontaine explains the complications with mesothelioma surgery.
If any symptoms occur in excess, you should contact your doctor. Excessive inflammation or foul-smelling drainage at the surgery site may be a sign of infection. Other signs of infection include redness and a warm or tingling sensation. Postoperative infection should be controlled under a doctor’s care, and it is imperative to report it immediately to prevent the infection from becoming fatal.
Managing Pain After Surgery
Discomfort after mesothelioma surgery may be dull and tingling or more intense. For some patients, the pain will occur when they stand, sit, walk or try to perform daily activities. But for others, the pain may occur even at rest.
Your surgeon can help you develop a pain management plan to cope with the discomfort you might experience after surgery. Before you leave the hospital, your doctor will most likely provide a prescription for an oral pain medication for moderate pain, such as Vicodin, or a narcotic for severe pain such as morphine.
Over-the-counter (OTC) medications, such as acetaminophen (Tylenol), ibuprofen (Advil) or naproxen (Aleve), may be recommended to relieve mild pain. However, OTC medications should not be taken after surgery without specific instructions from your doctor.
Karen Selby joined Asbestos.com in 2009. She is a registered nurse with a background in oncology and thoracic surgery and was the director of a tissue bank before becoming a Patient Advocate at The Mesothelioma Center. Karen has assisted surgeons with thoracic surgeries such as lung resections, lung transplants, pneumonectomies, pleurectomies and wedge resections. She is also a member of the Academy of Oncology Nurse & Patient Navigators. Read More
Pass, I., Vogelzang, N., Carbone, M. Malignant Mesothelioma: Advances in Pathogenesis, Diagnosis, and Transitional Therapies. Springer: New York. 2005.
Baldi, A., Mesothelioma from Bench Side to Clinic. Nova Biomedical Books: New York. 2008.
