Surgery is the most successful method for treating pleural or peritoneal mesothelioma. However, most mesothelioma specialists favor using surgery as part of multimodal therapy that also includes chemotherapy and radiation. Patients in all mesothelioma stages may be eligible for various surgical options.
Surgery is the best possible option for mesothelioma patients to live longer. There are life-extending procedures for both pleural and peritoneal mesothelioma.
Many more pleural mesothelioma patients are living past the 3-year mark. Pleural patients in stages 1-3 are the most common candidates for surgery. Some stage 4 patients are getting surgery as part of clinical trials.
Peritoneal mesothelioma patients have an even better outlook. It’s no longer uncommon for peritoneal patients to live years past their diagnosis. Specialists like Dr. Paul Sugarbaker are pushing patients beyond 5 and sometimes 7 years of survival.
Not every patient is a good candidate for surgery, but there are always other treatment options that can help you. Get more information about mesothelioma treatment in your free Mesothelioma Veterans Guide.
Are You Eligible for Surgery?
Before surgery, your doctors need to know if you are healthy enough and if you will be able to recover from it. This involves doing certain tests that measure your heart and lung health.
Common tests to determine eligibility for surgery include:
- Electrocardiogram (EKG)
- Cardiac stress test
- Pulmonary function tests
If these tests are normal, your doctor will consider doing surgery to help treat the mesothelioma.
Types of Surgeries
There are 3 broad types of mesothelioma surgery:
- Diagnostic – How cancer is discovered and diagnosed
- Curative – How cancer is treated successfully
- Palliative – Focused on relieving patient discomfort
Diagnostic surgeries help get biopsies of diseased tissue. Sometimes these surgeries are noninvasive. They only involve small incisions and placing a small camera to find tumors. Doctors remove a tissue sample through the tiny incision.
Other diagnostic surgeries are more invasive, full surgical procedures. Surgeons operate to get a better look at the extent of the disease.
Some surgeries used for diagnosis of mesothelioma include:
- Open lung biopsy
- Fine needle biopsy
- Core biopsy
- Excisional biopsy
The type of diagnostic surgery performed depends on the type of mesothelioma. It also depends on the skill and preference of the mesothelioma specialist.
Surgery can be done before or after chemotherapy and radiation. Chemotherapy before surgery is called neoadjuvant therapy, and after it is called adjuvant therapy.
If a patient has less advanced mesothelioma, surgery might be done with curative intent. The term “curative” is more of an expression in the medical field. With the treatment of any cancer, remission is the primary goal. Remission means there are no signs of cancer on test results, but doctors agree the cancer can come back. This is why some doctors don’t use the word “cure.” All the same, “curative surgery” is a common phrase used to describe the following treatments.
In curative surgeries, doctors remove all visible signs of mesothelioma tumors. Other organs and tissue may also be removed.
- Extrapleural Pneumonectomy (EPP). In this radical surgery, the entire affected lung is removed. Parts of the pleural lining and diaphragm are also removed. This is an invasive surgery that can be risky for some patients. It takes several weeks to recover from. Many people have lived long past their prognosis after receiving an EPP.
- Pleurectomy with Decortication (P/D). In this surgery, the cancer is removed along with the pleural lining. The surgeon doesn’t remove the lung or diaphragm. Dr. Robert Cameron developed this surgery at the UCLA Medical Center. It is less invasive than the EPP. People who have this surgery tend to live up to 19 months after having it performed. Some live even longer.
- Cytoreduction with HIPEC. This procedure is performed on patients with peritoneal mesothelioma. First, doctors remove all visible traces of cancer, then they put heated chemotherapy inside the abdomen, which helps kill off any remaining cancer cells. Some people who have had this type of surgery have lived 5 years or more.
Dr. Robert Cameron, who developed the lung-sparing P/D operation, treats veterans at the Los Angeles VA. He is one of the most respected mesothelioma surgeons in the world. Veterans in the VA can receive his curative surgery.
Sometimes surgery is done just to relieve symptoms. To cure the disease or extend the individual’s lifetime is not the goal of palliative surgery. The goal is to make patients comfortable. Palliative surgery is an option at any stage of mesothelioma.
Types of palliative surgery include the following:
- Pleurodesis. This procedure is for patients with pleural mesothelioma. It involves inserting a flexible tube into the chest wall so that fluid can drain from around the lung. In some cases, chemotherapy drugs (to kill cancer cells) are given after the fluid has been drained. The chemotherapy drug called bleomycin is sometimes used as part of the pleurodesis procedure.
- Thoracotomy. This is an incision in the chest wall. These procedures allow doctors to go inside the chest to remove large tumors and drain fluid. It helps reduce a patient’s pain and makes it easier to breathe.
- Paracentesis. This surgery is for patients with peritoneal mesothelioma. Like pleurodesis, a hollow tube is inserted into the patient. Doctors remove fluid from the abdomen so patients can feel less pressure and less shortness of breath.
- Segmentectomy. This is also called a wedge resection. Doctors remove cancer in one area of the lung, leaving the rest of the lung intact. It is less invasive to do this type of surgery than removing the entire lung. Segmentectomy does not remove all the cancer. Shortness of breath and chest pain can be relieved after this procedure.
- Lobectomy. One or more of the lobes of the lung are removed. It is used when the cancer appears in just one lobe of the lung. It is less invasive than removing the entire lung. A lobectomy can relieve symptoms.
- Shunt or catheter placement. Doctors put a tube in the pleural or peritoneal cavity so that fluid can continually drain from the area. This eliminates the need to do repeat surgeries to remove fluid that will continue to build up because of the cancer.
The type of mesothelioma surgery depends on the stage and cell type you have. It also depends on the preferences of your mesothelioma specialist. Each specialist has his or her own area of expertise and may prefer one type of surgery over another.
Pleural Mesothelioma Surgery Debate
There’s an ongoing debate about pleural mesothelioma. It has to do with which curative surgery is more effective. Is the radical EPP more effective? Some doctors argue that it can remove more of a patient’s cancer. Or is the lung-sparing P/D more effective? Doctors who favor P/D say that patients live longer if they keep both lungs. Let’s look at the arguments and what some doctors are saying.
This surgery has extended the lives of countless patients. Dr. David Sugarbaker designed the modern EPP and extended his patient’s lives by years with the addition of chemotherapy. The theory behind the EPP is to remove as much of the mesothelioma as possible.
But some doctors don’t agree that this is possible. They argue that the chest is too complex to get a full resection of tumors. There are only thin linings between the chest wall and lungs, not easy areas to operate in. P/D supporters think it’s better to remove what you can see and use chemo or radiation to treat what’s left.
Pleurectomy with Decortication
Dr. Robert Cameron is a staunch supporter of P/D. Like the EPP, P/D became effective once doctors learned the right combinations of other drugs to use with the surgery. Dr. Cameron even uses novel medications to treat his surgical patients.
Doctors in the P/D camp don’t just say it’s possible to remove most of the cancer with P/D. They say EPP doctors aren’t trying hard enough.
Dr. Cameron has even said, “Taking out a lung does harm and there is absolutely no benefit to the patient.”
There are some doctors dedicated to one surgery over the other, but there are numerous more dedicated to studying the benefits of both. Dr. Raja Flores has argued that there is a place for the EPP and the P/D. According to him, the right surgery depends on the specific patient. Older patients may benefit more with both lungs. Late stage patients may benefit more from EPP.
But every diagnosis is different and there are many factors to consider. There are some new approaches to the EPP where stage 3 and 4 patients are living more than 3 years. Yet the same has been true of novel approaches to P/D. There is a middle ground to these treatments that depend on each unique diagnosis.
Surgery is becoming a reality for more late-stage mesothelioma patients. Once patients reach stage 3 mesothelioma, their disease often becomes inoperable. But new treatment approaches are giving late-stage patients a chance. One treatment doctors are researching is P/D with photodynamic therapy. Photodynamic therapy uses a powerful light to kill mesothelioma cells during surgery. In one study, stage 3 and 4 patients who had this procedure had a median survival time of 3 years.
Mesothelioma doctors don’t prescribe surgery on its own. Surgical candidates also get chemotherapy or radiation to make surgery more effective.
“Patients with favorable prognostic factors can experience extended survival by undergoing trimodality therapy with extrapleural pneumonectomy, chemotherapy and/or radiation,” said the authors of a 2010 report. One of the authors of this report is renowned mesothelioma specialist Dr. David Sugarbaker.
Finding the Right Surgery
Potentially curative surgeries are your best bet if your disease isn’t advanced, though patients with advanced or metastasized mesothelioma have options too. Your doctor will help you minimize your pain and discomfort. And though it’s less common, some stage 4 patients have gotten life-extending surgery in clinical trials.
Key points on mesothelioma surgery:
- There are different surgeries for all patients no matter their diagnosis.
- Surgery can relieve painful symptoms.
- Surgery has led many patients to longer, happier lives.
There are cancer centers across the country where you can get surgical treatment. Even the VA in Los Angeles and Boston have mesothelioma specialists on board. Find out more about talking to a VA specialist and other VA benefits now.