There are several treatment options for mesothelioma, but few are as important as surgery. Mesothelioma surgery is a vital treatment for both reducing pain and possibly extending lifespans. After the diagnosis, most doctors will assess the patient’s eligibility for a major surgical procedure.
Not everyone will meet the requirements for major surgery. Some patients may already be in poor health while others may have been diagnosed with late-stage mesothelioma, making major surgery unviable as a treatment option.
Mesothelioma surgical procedures can be classified into three categories:
- Diagnostic – designed to identify the incidence of mesothelioma
- Curative – designed to get rid of the disease and extend lifespan
- Palliative – designed to reduce pain and discomfort and improve quality of life
Some surgeries for mesothelioma can overlap, falling into 2 or more of these categories. In any event, the first types of surgeries a mesothelioma patient will undergo are diagnostic in nature.
These surgeries are implemented with the goal of figuring out what is wrong with the patient. They are usually performed after imaging scans, and blood tests have identified some kind of issue. At the diagnostic stage, it will likely be unclear whether mesothelioma plays a role at all. Because mesothelioma is so rare, most doctors may suspect different diseases.
Diagnostic surgery types include:
- Needle aspiration – a least invasive surgical option that uses a needle to retrieve fluid from the affected area for study by a pathologist
- Camera-assisted (endoscopy) – minimally invasive procedures in which doctors insert a tube containing a camera into an incision and remove affected tissue
- Open surgery – most invasive option that provides doctors with a broader view of the affected area to more easily remove tissue for later study
Curative surgeries, on the other hand, are usually open surgeries that involve the full or partial removal of organs or tissues. The goal of these surgeries is to eliminate the disease by literally taking it out of the body. In many cases, cancerous cells remain even after the affected organs or tissues are removed. Chemotherapy and/or radiation therapy are often applied after major surgeries to avoid recurrence of the disease.
Palliative surgeries are carried out with the express goal of reducing pain and improving quality of life. Patients who undergo palliative surgeries are not expected to survive long-term. Because of this, these mesothelioma surgeries are usually minimally-invasive with much shorter recovery times.
Thoracentesis, Paracentesis, and Pericardiocentesis
These three procedures can be used as a mesothelioma treatment or a diagnostic tool. They are all performed using a hollow needle to draw fluid from the body. They only require a local anesthetic and are relatively non-painful. Recovery times for the needle aspiration procedures are minimal, and most patients are able to return home immediately after the procedure.
Thoracentesis is used in cases of pleural mesothelioma, which is the most common type of the disease and occurs in the lung lining known as the pleura. The disease causes a buildup of fluids (called pleural effusion) between the layers of the lung lining. The buildup can put pressure on the lungs or nearby organs, causing pain for the patient. The procedure is usually executed with the patient in a seated position. The needle is inserted between the ribs using the guidance of a CT scanner or ultrasound machine. The procedure usually only takes about 15 minutes.
Paracentesis is used for patients with peritoneal mesothelioma, which is the second-most common type of the disease and occurs in the lining of the abdominal cavity. Like with pleural mesothelioma, peritoneal mesothelioma causes excessive fluid buildup (called ascites or ascitic fluid) around the abdominal cavity. A hollow needle is placed through the abdomen using an ultrasound as a guide. The fluid is then drained. The procedure takes only about 20 to 30 minutes.
The same concept applies to pericardiocentesis except that it is used for the removal of fluid around the lining of the heart (pericardium). This procedure is performed for pericardial mesothelioma, but it can also be performed for cases in which pleural or peritoneal mesothelioma have metastasized (or spread) to the heart lining. An echocardiogram is used to guide the specialist.
All of these procedures are generally considered safe and have very few risks involved. Common complications include pain, minor bleeding, or persistent fluid leakage. Again, all of these procedures can be used as diagnostic tools or palliative treatments.
Endoscopies and Pleurodesis
Endoscopies can have a wide range of uses. In fact, they can be diagnostic, curative, or palliative in nature. Most endoscopies involve a small incision near the tumor site. A tube with a camera on the end is inserted into the incision which surgeons use to help guide them.
When used in a diagnostic sense, the goal is to remove a biopsy of the tumor for further study. Tissue biopsies are more reliable than fluid samples retrieved from needle aspiration in determining whether mesothelioma is present.
Different endoscopies are performed for each form of the disease. These include:
- Thoracoscopy (occurring in the chest cavity for pleural mesothelioma)
- Laparoscopy (occurring in the abdominal cavity for peritoneal mesothelioma)
- Mediastinoscopy (occurring in the mediastinum for pericardial mesothelioma)
These camera-assisted surgeries are often minimally-invasive and have a recovery time of only a few days to a week. They are also used in lieu of much more invasive diagnostic surgeries like a thoracotomy (for pleural and pericardial mesothelioma) or laparotomy (for peritoneal mesothelioma).
A thoracoscopy can occasionally be used to perform a minor surgery. Under these circumstances, it is usually referred to as a video-assisted thoracoscopic surgery (VATS). One procedure in which VATS is used is called pleurodesis. This minor surgery is palliative in nature, only seeking to reduce fluid buildup in the lungs and the associated pain and complications.
It involves injecting a binding substance (most commonly talc) in the pleural space between the chest wall and the lungs. The talc causes both the chest wall and the lung lining to become irritated and inflamed. The goal is to cause those pleural linings to fuse together so that fluid buildup can no longer occur in that space. Recovery time for this surgery is usually about a week.
Pleural Mesothelioma Tumor Removal Surgeries
Of all mesothelioma surgical procedures, there is none more invasive than one that seeks to remove tumors and diseased tissues. These surgeries often involve the complete or partial removal of an organ or tissue and any associated tumors.
Most mesothelioma patients are not good candidates for major surgery because of the procedures. Patients in bad health or those whose mesothelioma has spread to distant parts of the body (usually in stage 3 or 4 of the disease) will often not benefit from major surgery.
For those who can benefit, however, a major surgical procedure can prove to be extremely valuable. Each type of mesothelioma has different surgical procedures that can be implemented.
For pleural mesothelioma, there are generally three major surgeries that can be performed:
- Pleurectomy decortication
- Extrapleural pneumonectomy
All three of these surgeries require an incision (called a thoracotomy) that starts from the middle of the back and curves around to the chest wall. The first option that a physician will consider is a pleurectomy decortication. This procedure is the only one that saves the lung from being completely removed. It is a two-part surgery that begins with a pleurectomy.
During this procedure, the surgeon removes the lining of the chest cavity (known as the parietal pleural membrane) which reveals the outer lining of the lung (visceral pleural membrane). The decortication then removes that lung lining from the lung itself and eliminates any tumors or clusters of cancerous cells in the nearby area. Patients are usually hospitalized for up to two weeks, and full recovery can take a few weeks to 2 months. An alternative version of this procedure uses video-assisted thoracoscopic surgery (VATS), which is less invasive but may not be as effective.
A pneumonectomy refers to a surgery that involves the removal of a lung. For mesothelioma, surgeons will most often opt for an extrapleural pneumonectomy (EPP) which offers further disease removal.
With an EPP, all of the following are removed:
- Diseased lung
- Pleural lining of the chest wall
- Lining of the heart
- Portion of the diaphragm
This procedure can take anywhere from 10 to 12 hours to complete. It is one of the most aggressive and invasive surgeries a mesothelioma sufferer can face, and, as such, they can expect a hospital stay of 2 weeks or more. The space vacated by the lung will fill with fluid over the course of the following 4 months. Patients can usually return to normal activities by 2 to 3 months after the surgery.
Despite the risks involved in any major surgery, these options mostly provide positive outcomes for patients. After a pleurectomy decortication, 5-year patient survival rates have reached up to 40%. Disease recurrence, however, occurs about 65% of the time. With an EPP, the rate of disease recurrence is only 33%. Chemotherapy and radiation therapy can help keep recurrence rates down.
In general, these surgeries help eliminate symptoms like:
- Difficulty breathing
- Persistent cough
- Pleural effusion
- Chest pain
Other Tumor Removal Surgeries
The other two main forms of mesothelioma, peritoneal and pericardial, also have their own major tumor removal surgeries. With peritoneal mesothelioma, those surgeries are the peritonectomy and cytoreductive surgery. A peritonectomy involves the removal of the diseased portions of the lining of the abdominal cavity. It is often paired with cytoreductive surgery which essentially excises tumors in other parts of the abdomen.
To remove those tumors, surgeons may eliminate portions of a variety of organs, including:
This surgery also often involves another treatment: hyperthermic (heated) intraperitoneal chemotherapy (HIPEC). This therapy involves using heated chemotherapy drugs and injecting them into the tumor sites in the middle of surgery. It is a much more effective delivery method for chemotherapy drugs and has shown great efficacy in improving survival rates. Five-year survival rates for patients who underwent surgery with HIPEC are over 50%.
Patients are usually hospitalized for 1 to 2 weeks after surgery. This mesothelioma surgery recovery time really depends on how well the digestive system responds to the treatment, particularly if parts of the intestines or stomach were removed.
For pericardial mesothelioma, the main surgical option is a pericardiectomy. This involves the removal of the pericardium (heart sac lining). This treatment can be either curative or palliative. The surgery often helps improve heart function while eliminating fluid buildup and reducing pain. Patients are usually hospitalized 1 to 2 weeks after surgery.
Because there are so few cases of pericardial mesothelioma that are ever diagnosed, there is little data on how positively this procedure affects life spans.
Robotic Mesothelioma Surgery
In recent years, a new surgical technique has been developed that can greatly improve the success of even the toughest procedures. Robotic surgery uses a small remotely controlled robot with tiny hands and a mounted camera to perform the surgery without a major incision. In fact, the small robot can fit into a relatively small incision, and the doctor can control it with fewer risks.
Robotic surgery can be used as both a diagnostic and curative measure. Diagnostically, the robot can identify whether a patient qualifies for major surgery. As a curative measure, doctors can use the robot to perform even the toughest surgeries like an extrapleural pneumonectomy.
This can obviously provide many benefits to the patient, including:
- More precise movements to more thoroughly remove cancerous growths
- Better detection of cancerous cells and tumor growths
- Far less invasive than most major surgical options
- Limited blood loss
- Fewer overall complications
- Hospitalization of only a few days rather than weeks
Unfortunately, this option is relatively new, and many doctors are not skilled enough in it for competent implementation. It also just isn’t an option in many hospitals. Even so, there is no question that a robotic surgery could change how mesothelioma is treated in the future. It can also be a valuable tool in identifying which patients are viable candidates for major surgery.
As research in this area progresses, more and more doctors will become proficient at using robotics, possibly improving mesothelioma prognoses overall.