Surgery for Malignant Mesothelioma

Surgery for mesothelioma may be done:

• To try to cure the cancer (potentially curative surgery)
• To relieve pain and other symptoms caused by the tumor (palliative surgery)

Potentially curative surgery may be an option if you're in otherwise good health and the cancer can be removed completely. But even when the surgeon removes all of the cancer that can be seen, some cancer cells are often left behind. These cells can grow and divide, causing the cancer to come back after surgery. Because of this, not all doctors agree on the exact role of surgery. In most cases it won't cure you, but it could help you live longer. Still, potentially curative surgery is being done in some major cancer centers, and a small number of people who have had the surgery have had long periods of time with no sign of cancer.

Palliative surgery may be an option if the tumor has already spread beyond where it started and would be hard to remove completely. It may also be used if you're too ill for a more extensive operation. The goal of this surgery is to ease or prevent symptoms, not to cure the cancer.

Types of surgery for pleural mesothelioma

Either potentially curative or palliative surgery might be used for pleural mesothelioma. But in most cases, these tumors have spread too far to be removed completely. Sometimes, the surgeon might not be able to tell the full extent of the cancer – and not know which type of surgery might be best – until the operation has started.

Extrapleural pneumonectomy (EPP): This is a major operation, but it may offer the best chance to remove all of the cancer for many patients. It might be used when the surgeon thinks a cure is possible – mostly in patients with resectable epithelioid mesothelioma that has not spread to the lymph nodes.

In EEP, the surgeon removes the lung on the side of the cancer along with the pleura lining the chest wall on that side, the diaphragm (thin breathing muscle) on that side, maybe the pericardium (the sac around the heart), and nearby lymph nodes. The diaphragm and the pericardium are then rebuilt with man-made materials.

This is a complex operation that's only done by experienced surgeons in large medical centers. You must be in good overall health with good lung function and no other serious illnesses to withstand EEP. A lot of tests must be done beforehand to be sure you’re healthy enough for this surgery. About 1 in 3 patients who have this operation can have major complications.

Pleurectomy/decortication (P/D): This is a less extensive operation in which all of the pleura lining the chest wall (on the side with the cancer) is removed, along with the pleura coating the lung on that same side. The pleura coating the mediastinum and the diaphragm is also removed. The lung and diaphragm muscle are not removed.

In a slightly more extensive version of this operation ( a radical or extended P/D), the diaphragm on the side with cancer and/or pericardium are removed too.

This surgery can be used to try to cure some early cancers, but it can also be used as a palliative procedure to relieve symptoms if the entire tumor can’t be removed. It can help control the buildup of fluid, improve breathing, and lessen pain caused by the cancer.

Debulking (partial pleurectomy): The goal of this surgery is to remove as much of the cancer and mesothelioma as possible. In general, less tissue is removed in this operation than in a P/D procedure.

Possible side effects of surgery

The operations used to treat mesothelioma can have serious risks and side effects, which depend on the extent of the surgery and the person’s health beforehand. Serious complications of EPP can include bleeding, blood clots, wound infections, changes in heart rhythm, pneumonia, fluid build-up in the chest, and loss of lung function. These tend to be less common with less extensive operations.

Because the surgeon must often spread the ribs during surgery, the incision will hurt for some time afterward. Your activity will be limited for at least a month or two.

Studies have suggested that P/D is preferred because there are fewer problems linked to it, and overall outcomes are much the same as, if not better than EPP. P/D tends to be used more often in most treatment centers, but more studies are needed to compare the 2 surgeries. At this time the type of surgery used depends on the hospital and surgeon's experience along with the details of each patient's cancer and overall health, as well as their personal preferences.

Surgery for peritoneal mesothelioma

Surgery for peritoneal mesothelioma can be used to help ease symptoms or to remove the tumor from the wall of the abdomen (belly) and digestive organs. As is the case with pleural mesothelioma, these tumors often have spread too far to be removed completely.

Debulking: The goal of this surgery is to remove as much of the mesothelioma as possible. Sometimes this means removing pieces of the intestine as well.

After as much of the visible cancer is removed as possible (but before the operation is finished), chemotherapy may be put into the abdomen. This is called intraoperative or intraperitoneal chemotherapy. If the chemotherapy drugs are heated, it's called heated intraoperative chemotherapy or HIPEC. In either treatment, the drugs are left in for a short time, then they're removed and the incision is closed.

Omentectomy: The omentum is an apron-like layer of fatty tissue that drapes over the organs inside the abdomen. Cancers in the peritoneum often spread to this tissue, so it may be removed as part of surgery for peritoneal mesothelioma.

Surgery for pericardial mesothelioma

Surgery can remove a mesothelioma from the pericardium (the sac around the heart). The entire pericardium may be removed (called a pericardectomy) can be removed to ease pressure on the heart. Surgery may be done to make a hole in the pericardium, which is called a pericardial window. This can be used to put chemo into the area around the heart.

Surgery for mesothelioma of the tunica vaginalis

Surgery for mesothelioma of the tunica vaginalis, which covers the testicles, rarely cures this cancer. Most of the time surgery is done when the tumor is mistaken for a hernia. The surgeon attempts to treat a suspected hernia and only realizes the diagnosis after the surgery has begun. This kind of mesothelioma can seldom be removed entirely.