Surgery may be recommended by doctors when treating pleural mesothelioma patients, especially in cases where the patient’s health is good overall and the cancer has not spread too far. Research confirms and mesothelioma specialists agree that it is the best option for long-term survival with this disease.
Although pleural mesothelioma is not curable, surgery can provide the closest form of curative treatment for malignant pleural mesothelioma. Many survivors have outlived their original prognosis after undergoing surgery.
Your doctor will decide if surgery is right for you. Every patient may not need or qualify for the same type of surgery.
Surgeries to treat pleural mesothelioma can vary, but typically fall into three categories: diagnostic, potentially curative and palliative.
Diagnostic surgery is used to confirm the presence of cancer. It is the most basic type of surgery and is often done with a biopsy, which is tissue removal from the body. Some of the most common biopsies include fine-needle aspiration, excisional biopsy, incision/core biopsy and thoracoscopy.
There are two major tumor-removing surgery options for pleural mesothelioma: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). Both procedures are extensive and require an experienced mesothelioma surgeon, but the experts disagree on which procedure is more beneficial.
An extrapleural pneumonectomy (EPP) involves the removal of an entire lung, the lining around the lung and parts of the diaphragm. The surgeon then rebuilds the diaphragm with replacement parts. It is life-changing, but patients can live a long time with only one lung if they are willing to alter their lifestyle. It does have considerable risk of complications, and recovery can take several months.
A 2018 single-center study of EPP published in the European Journal of Cardio-Thoracic Surgery produced a 33.2-month median survival and a 24.2 percent five-year survival.
Pleurectomy and decortication (P/D), which is also known as lung-sparing surgery, has shown equally impressive results for some patients, with fewer complications and a quicker recovery than an EPP. The lung remains intact, but the pleura lining surrounding the lung is completely removed, as are all visible tumors on the lung and chest wall. It is considerably more detailed than an EPP.
A study published in January 2019 in Seminars in Thoracic and Cardiovascular Surgery showed patients who underwent a pleurectomy and decortication had a longer median survival than patients who received an EPP.
There has been in-depth debate over the pros and cons of each type of surgery. There are surgeons who believe the EPP has no place in the treatment of pleural mesothelioma because the cancer eventually will return. Others, however, believe it offers the best chance for long-term survival.
The latest advancement in the EPP debate is robotics, which could change the perception of this procedure. Although robotics have been used in less invasive thoracic surgery for a decade, Farid Gharagozloo, M.D., of the University of Arizona Cancer Center, performed the first EPP with the da Vinci Surgical System Robot in early 2013. He has done several more EPP procedures since with impressive results.
In robotic surgery, the doctor works on a computer board while tiny robotic instruments do the work. It allows for more precise movements and a more magnified view, and dramatically reduces blood loss. It reduces the stress on the remaining lung, and leads to a much faster recovery.
A debulking surgery is another surgical procedure that has a curative intent, but rarely produces the life spans offered by the EPP and P/D. Debulking attempts to remove as much of the cancer as possible, but it generally removes less tissue than a P/D.
Palliative surgery is designed to reduce pain and symptoms associated with pleural mesothelioma. It is not designed to be curative, but in many cases, it helps produce a better quality of life for a patient.
One of the most difficult symptoms of advanced pleural mesothelioma is difficulty breathing, which is a result of fluid buildup in the lungs. There are two surgical procedures that are used to alleviate this problem: thoracentesis and pleurodesis.
Thoracentesis, also known as pleurocentesis and pleural tap, refers to a procedure in which a long, thin needle is inserted into the pleural space around the lungs to drain fluid and relieve pain. It can be done in a doctor’s office with a local anesthetic. Patients return home an hour or two after the procedure. Thoracentesis also can be used for diagnostic purposes.
During this in-patient procedure, a surgeon injects talc into the space between the layers of the pleura and then suctions it out. Scar tissue will develop, effectively sealing the pleura and preventing further fluid buildup. It is performed under general anesthesia and is considered one of the most effective palliative treatments for pleural mesothelioma. In fact, according to the American Cancer Society, an estimated 90 percent of patients receive some relief after a pleurodesis.
Severity of surgical side effects will vary depending upon whether the procedure was minor or aggressive. Potentially curative surgeries present the highest risk of complications, while most diagnostic procedures lead to fewer side effects.
The most common side effect of all surgeries is pain around the incision site. Pain medicine and topical ointments can help with incision pain. Make sure to clean the incision properly to prevent infection. If you suspect an infection because of excessive redness, swelling or drainage at the site, contact your doctor immediately for medical treatment. Bleeding around the incision is normal, but excessive bleeding requires medical attention.
Fatigue is another common side effect of all pleural mesothelioma surgeries. The body undergoes much stress from surgery and requires lots of energy to recover. Get adequate rest and consume enough calories to sustain energy so the body can recover.
Cardiac problems may develop from more aggressive surgeries. The most common cardiac side effect is an abnormal heartbeat. Other cardiac complications include inflammation, compression caused by fluid accumulation or a heart attack.
A heart attack is a rare complication that may happen while the patient is recovering from surgery in the hospital, where swift medical attention is accessible.
Pneumonia, respiratory failure, aspiration, air leakage, blood clot and hemorrhage are other rare complications that also are quickly treated in a hospital setting.
Minor surgical procedures are easier to recover from than aggressive surgeries which remove parts of the lung or an entire lung. For example, certain diagnostic surgeries, such as a thoracentesis, are so minor that they’re done on an outpatient basis and require minimal recovery time.
Conversely, an EPP or P/D surgery may require two or more weeks recovery time in a hospital. Respirators to aid breathing and chest tubes to drain fluid from the lungs will be used in the days following these potentially curative surgeries. Because an entire lung is removed in an EPP surgery, full recovery can take up to two months or longer.
Getting lots of rest and sleep is essential to recovery. Conserving energy and consuming enough calories and protein will aid the recovery process. Make sure to eat well, because the body needs adequate protein and nutrients to repair wounds and cope with potential side effects of surgery.
Working with a palliative care doctor will ensure proper pain medication is prescribed. Nurses will teach breathing exercises and coughing techniques to help you prevent pneumonia. After being released from the hospital, pulmonary rehabilitation can make breathing easier for patients who underwent an aggressive surgery.
The surgeon of the patient’s choosing will likely recommend other specialists as a part of a team approach to the overall care that may include a radiologist, a pulmonologist and an oncologist, among others.
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