Mesothelioma Surgery

When it comes to mesothelioma, surgery is often the best treatment option for extending life expectancy. Patients with stage one or stage two mesothelioma are often eligible for life-extending surgery, which involves removing mesothelioma from the lining of the lung, abdomen or heart, as well as removing any visible tumors. Surgery is also often combined with other treatments, like chemotherapy and sometimes radiation therapy, to increase its effectiveness.

For patients diagnosed with late-stage mesothelioma, doctors can improve their quality of life with palliative surgery, which relieves pain caused or other symptoms of the disease.

Contact a member of our Patient Help Team to find out if surgery may be an option for you.

• Extrapleural pneumonectomy (EPP). Some consider the EPP to be the “gold standard” of treatment for pleural mesothelioma, but it is uncommonly performed because most people are not suitable candidates. The surgery involves removing the affected lung and surrounding tissue, and is often combined with intraoperative chemotherapy to increase survival time.
• Pleurectomy/decortication (P/D). P/D is a lung-sparing surgery often used as an alternative to the EPP. During P/D, surgeons remove the diseased lining of the lung and any visible tumors or cancerous tissue on the surface of the lung. P/D may becombined with intraoperative radiation to help achieve clear margins.
• Hyperthermic Intrathoracic Chemotherapy (HITHOC). HITHOC allows surgeons to deliver chemotherapy drugs directly to the chest cavity during surgery. This procedure may be recommended after a pleurectomy and decortication. HITHOC has similarities to HIPEC, which is used to treat mesothelioma in the abdomen.
• Pleurodesis (talc procedure). Typically used for pleural mesothelioma, this procedure eliminates the recurrence of fluid in the chest or pleural cavity.  Some patients are just more prone to developing fluid (pleural effusions) in the lining of their lungs than others. When fluid builds up, it can cause shortness of breath, discomfort, and ultimately a collapsed lung.  Pleurodesis uses chemicals or talc to scar the space between the layers of the pleura so fluid cannot accumulate there.  It may be recommended that a patient have an Indwelling Pleural Catheter placed instead of this surgery; the catheter or port allows patients to drain their fluid as needed at home.

Peritoneal Mesothelioma Procedures

• Peritonectomy. A peritonectomy is often performed using a technique called cytoreductive surgery, which involves up to six different procedures aimed at removing as much of the cancer as possible. This intensive treatment is recommended only for early-stage peritoneal mesothelioma and for individuals who are otherwise very fit.
• Cytoreduction with HIPEC. For patients with peritoneal mesothelioma, cytoreduction with HIPEC is used to remove the affected lining of the abdomen and surrounding tumors. Heated intraperitoneal chemotherapy (HIPEC) is then applied to kill remaining mesothelioma cells.  HIPEC has proven very effective for many peritoneal mesothelioma patients.
• Early Postoperative Intraperitoneal Chemotherapy (EPIC). A type of chemotherapy delivered to the abdomen through a thin tube, EPIC is administered right after surgery while a patient is still in recovery.
• Normothermic Intraperitoneal Chemotherapy (NIPEC). Administered through a port into the abdomen four to six weeks post-surgery, NIPEC is an unheated type of chemotherapy.

Pericardial Mesothelioma Procedures

• Pericardiectomy. For patients with pericardial mesothelioma, surgeons use pericardiectomy to remove the diseased lining of the heart and any visible tumors.  This surgery may be followed by a course of chemotherapy.
• Palliative surgery. Palliative surgical procedures are designed with the goal of relieving pain and symptoms for patients with late-stage mesothelioma who are ineligible for potentially curative surgery. However, in some cases, early-stage patients can also benefit from palliative treatment.

Your doctor determines your surgery eligibility when you’re diagnosed with mesothelioma.

If you’ve already been diagnosed, it’s important to get a second opinion to make sure you’re aware of all possible treatment options—including surgery.

The goal of pleural mesothelioma surgery is to remove tumors and other cancerous tissue from the chest cavity and the lining of the lungs (the pleura). Eligible pleural mesothelioma patients have two surgical options: an extrapleural pneumonectomy (EPP) or a pleurectomy with decortication (P/D).Doctors and oncologists may also recommend additional treatment options for the management of malignant pleural mesothelioma. Even patients who undergo surgery may first have chemotherapy to shrink their tumors as much as possible, or chemotherapy afterward to address any cancer cells that the surgeon was not able to safely remove or visualize.

To perform an EPP, surgeons remove the entire lung affected by the tumors, and depending on the specific case, may also opt to remove some of the surrounding lymph nodes, the lining of the chest wall, parts of the diaphragm, and the lining of the heart. They then replace the removed parts from the diaphragm and lining of the heart with a breathable fabric membrane.

The EPP is most effective for patients with stage 1 or stage 2 mesothelioma since, at these stages, it’s possible for surgeons to remove most of the cancerous tissue because the tumors are limited to the lining of one lung and have not spread too far.

Mesothelioma cell type also determines how effective an EPP will be. Patients diagnosed with an epithelioid cell type have a better chance at an improved prognosis. In fact, a recent study showed that patients with epithelioid mesothelioma had higher 2- and 5-year survival rates than those with sarcomatoid and biphasic mesothelioma.

To perform a pleurectomy with decortication (P/D), a surgeon removes the lining of the lung affected by mesothelioma and all visible tumors in the surrounding area. Doctors call the P/D a lung saving surgery because — unlike the EPP — doctors don’t remove an entire lung during the procedure.

The first steps of the P/D and the EPP are similar: both begin with a thoracotomy, an incision that opens the chest. Instead of removing an entire lung—as they would during an EPP—your surgeon will perform a pleurectomy, the removal of the inner and outer lining of the lung affected by tumor growth. After the pleurectomy is completed, they’ll perform a decortication, scraping the surface of the lung to remove all visible tumors.

Your oncologist may recommend an extended or partial pleurectomy. An extended pleurectomy resects (cuts out) the pleura as well as cancerous parts of the diaphragm and/or pericardium. A partial pleurectomy is often referred to as “debulking” and removes less tissue compared to a regular P/D procedure. A partial pleurectomy may be done as part of palliative care. 

The goal of peritoneal mesothelioma surgery is to remove as much cancerous tissue from the lining of the abdomen (the peritoneum) as possible. The most common surgical procedures for peritoneal mesothelioma patients are cytoreduction and heated intraperitoneal chemotherapy (HIPEC), which in many cases, have added years to patients’ lives. 

Surgeons use cytoreductive surgery to remove as much tumor growth from the lining of the abdominal cavity as possible. Depending on how far the mesothelioma has spread, the surgeon may also remove parts of the gall bladder, pancreas, and stomach.

Most peritoneal mesothelioma patients eligible for cytoreduction receive HIPEC. During this procedure, a surgeon introduces heated chemotherapy into the abdominal cavity during surgery. Combining surgery and heated drugs raises the effectiveness of each. Cytoreduction reduces the tumor mass while the heated drugs kill microscopic cancer cells left behind during the surgery. 

Pericardial mesothelioma, which impacts the lining of the heart (pericardium), is the rarest form of the disease. Doctors do not see many cases, so surgical options are still being refined. Nevertheless, patients still have surgical treatment options if they have been diagnosed with mesothelioma in the lining of their heart.

Doctors use palliative surgery to relieve pain caused by tumor growth for patients with all stages of mesothelioma. 

• Pleurodesis. Doctors use a surgical procedure to seal the pleural cavity, which is the space between the inner and outer lining of the lung. Sealing this cavity reduces pressure caused by pleural effusions (the buildup of fluid in the lining of the lungs), and prevents them from recurring.  During a pleurodesis, surgeons may remove existing fluid and perform a biopsy.
• Indwelling Pleural Catheter (IPC). IPC is a palliative treatment for patients with frequently recurring pleural effusions. By making a small incision in the chest, doctors can insert a catheter — sometimes called a port — into the lung’s lining which allows patients to drain excess fluid in the comfort of their own home.  By draining fluid frequently, patients can breathe more easily and have a lower risk of a collapsed lung.  It is becoming more common for patients to have an IPC placed rather than undergo pleurodesis.
• Thoracentesis. During this procedure, providers (often radiologists) use a needle to remove excess fluid in the lining of the lung affected by tumor growth.  Sometimes the fluid is tested and you will receive a cytology report.  Note that a “negative” cytology report does not rule out mesothelioma.  The fluid is a symptom of the cancer and not the cancerous tissue itself.
• Paracentesis. Similar to thoracentesis, paracentesis involves removing excess fluid with a needle from the lining of the abdomen.  Sometimes the fluid is tested and you will receive a cytology report.  Note that a “negative” cytology report does not rule out mesothelioma.  The fluid is a symptom of the cancer and not the cancerous tissue itself.
  

Side Effects of Mesothelioma Surgery

All mesothelioma surgical procedures carry risks. Whether or not a patient will experience any adverse events depends on many factors including the type and stage of mesothelioma, the age and health of the patient, and even the experience of the surgeons and hospital involved. And depending on the type of surgery performed, you may experience different risks, side effects and recovery times.

Side effects of mesothelioma surgery may include:

• Abdominal or chest pain
• Air leakage in the lung wall
• Blood clots
• Changes to heart rhythm
• Fatigue
• Gastroparesis
• Infection
• Internal bleeding
• Pleural effusion
• Pneumonia
• Respiratory failure
• Shortness of breath

Mesothelioma patients will receive follow-up care from their oncologist, who will provide support and pain relief when necessary throughout the recovery process.

Surgery is likely the best option available for improving your prognosis, and most patients have at least one surgical option available—whether it’s curative, palliative, or both.

Learn more about your treatment options by speaking with a member of our Patient Help Team. We’ll review your diagnosis, help you find ways to pay for treatment, and can even connect you to experienced doctors—all for free.

You can also learn more about mesothelioma, treatment options, and ways to stay healthy by getting a free copy of our informational guide.