Surgery for malignant mesothelioma

Surgery for mesothelioma may be done for 1 of 2 reasons:

• To try to cure the cancer
• To relieve (palliate) pain and other symptoms caused by the tumor

Surgery to try to cure the cancer is known as potentially curative surgery. This type of surgery may be an option if you are in otherwise good health and the cancer has not spread too far to be removed completely. Unfortunately, even when the surgeon can remove 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 some time after surgery. Because of this, not all doctors agree on the exact role of surgery. In most cases it is not likely to cure you but may extend your life. Still, potentially curative surgery is being done in some major cancer centers, and a small number of patients who have had the surgery have had long remissions of their disease.

Palliative surgery may be an option if the tumor has already spread beyond where it started and is difficult to remove completely, or if you are too ill for a more extensive operation. The goal of this surgery is to relieve or prevent symptoms, as opposed to trying to cure the cancer.

Surgery for pleural mesothelioma

Surgery for pleural mesothelioma may be done either to help prevent or relieve symptoms or to try to remove all of the cancer. Unfortunately, these tumors have often spread too far to be removed completely. Sometimes, the surgeon may not be able to tell the full extent of the cancer – and therefore which type of surgery might be best – until the operation has started.

Extrapleural pneumonectomy (EPP): This surgery may offer the best chance to remove all of the cancer, and it is most often used when the surgeon thinks a cure is possible – typically in patients with resectable mesothelioma of the epithelioid type whose cancer has not spread to the lymph nodes.

This is an extensive operation that removes the pleura lining the chest wall, part of the diaphragm, the pericardium (the sac around the heart), nearby lymph nodes, and the whole lung on the side of the tumor. The diaphragm and the pericardium are then reconstructed with man-made materials.

This is a difficult operation and is done only by surgeons in large medical centers. You must be in good overall health with good lung function and no other serious illnesses to tolerate this surgery. Several tests must be done beforehand to be sure you are healthy enough for this surgery. Major complications occur in as many as 1 in 3 people who have this operation.

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

In a slightly more extensive version of this operation (known as a radical or extended P/D), the diaphragm and pericardium are removed as well.

This surgery can be used to try to cure some cancers, but it is also used as a palliative procedure to relieve symptoms in cases where the entire tumor cannot be removed. It can help control the buildup of fluid, improve breathing, and decrease pain caused by the cancer.

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

Possible side effects of surgery: Possible risks and side effects 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, and loss of lung function. Most of these are 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.

Surgery for peritoneal mesothelioma

Surgical treatment of peritoneal mesothelioma is often done either to help relieve symptoms or to remove the tumor from the wall of the abdomen and digestive organs. As 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.

Omentectomy: The omentum is an apron-like layer of fatty tissue that drapes over the contents of the abdomen. Cancers involving 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 be done to remove a mesothelioma from the pericardium (the sac around the heart).

Surgery for mesothelioma of the tunica vaginalis testis

Surgery for mesothelioma of the tunica vaginalis testis, which occurs in the groin, rarely cures this cancer. Most of the time surgery is done because the tumor resembles a hernia. The surgeon attempts to treat a suspected hernia and only realizes the diagnosis after the surgery has begun. This kind of mesothelioma typically can't be removed entirely.

Other palliative procedures

Several less invasive procedures can be used to control some of the symptoms caused by mesothelioma, especially those due to the buildup of fluid.

Removal of fluid: Procedures such as thoracentesis, paracentesis, and pericardiocentesis can be used to remove fluid that has built up and is causing symptoms. In these procedures, a doctor uses a long, hollow needle to remove the fluid. These procedures are described in the section, “How is malignant mesothelioma diagnosed?” The major drawback with these techniques is that the fluid often builds up again, so they may need to be repeated.

Pleurodesis: This procedure may be done to try to prevent fluid from building up in the chest. A small cut is made in the skin of chest wall, and a hollow tube (called a chest tube) is placed into the chest so that the fluid can drain out. Then the doctor uses the tube to put a substance into the chest, such as talc mixed in a fluid (talc slurry), the antibiotic doxycycline, or the chemotherapy drug bleomycin. Talc powder can also be sprayed into the chest cavity as an aerosol from a pressurized can. This causes the linings of the lung (visceral pleura) and chest wall (parietal pleural) to stick together, sealing the space and preventing further fluid buildup. The tube is generally left in for a day or two to drain any new fluid that might accumulate. Pleurodesis can also be done at the time of thoracoscopy.

Shunt placement: A shunt is a device that allows fluid to move from one part of the body to another. For example, a pleuro-peritoneal shunt lets fluid in the chest move into the abdomen, where it is more likely to be absorbed by the body.

The shunt is a long, thin, flexible tube with a small pump in the middle. In the operating room, the doctor inserts one end of the shunt into the chest cavity and the other end into the peritoneum. (The pump is placed just under the skin over the ribs.) Once the shunt is in place, the patient uses the pump several times a day to move the fluid from the chest to the abdomen. This approach may be used if pleurodesis or other techniques are not effective.

Catheter placement: This is another approach sometimes used to control the buildup of fluid. One end of the catheter (a thin, flexible tube) is placed in the chest or abdomen through a small cut in the skin, and the other end is left outside the body. This is done in a doctor’s office or hospital. Once in place, the catheter can be attached to a special bottle or other device to allow the fluid to drain out on a regular basis.

For more general information about surgery, please see our document, Understanding Cancer Surgery: A Guide for Patients and Families.