Pleural mesothelioma surgeries include pleurectomy and decortication(P/D), which removes all cancer tissue around the lung, and extrapleural pneumonectomy (EPP), which removes the lung as well. Surgeries to reduce pleural mesothelioma symptoms include thoracentesis and pleurodesis.
Choosing the Best Pleural Mesothelioma Surgery
The best pleural mesothelioma surgery depends on a patient’s overall health and how far the cancer has spread. For eligible patients, major tumor-removing surgery provides the best chance of long-term survival. Other patients can benefit from minor procedures that relieve symptoms.
Pleural mesothelioma surgery is usually combined with other treatments such as chemotherapy or radiation therapy. There is no cure for pleural mesothelioma, but treatment plans including surgery have helped many survivors outlive their original prognosis by years.
You must decide with your doctor if surgery is right for you. Different types of surgery are appropriate for different patients.
Surgeries used in pleural mesothelioma treatment typically fall into three categories:
Diagnostic Surgeries for Mesothelioma
Diagnostic surgery is used to confirm the presence of pleural mesothelioma cancer. It is the most basic type of surgery and often takes the form of a biopsy, which removes a sample of tissue from the body.
- Fine-Needle Aspiration: Uses a long needle to remove a sample of cells from a tumor.
- Incisional/Core Biopsy: Removes a small section of tissue from a tumor.
- Thoracoscopy: Uses a small probe with a camera to inspect a tumor and remove a tissue sample without the need for an invasive procedure.
Surgeries for Managing Mesothelioma Pain
Palliative surgery treats pleural mesothelioma symptoms, giving the patient better quality of life.
Two of the worst symptoms of advanced pleural mesothelioma are pain and breathing difficulty caused by fluid buildup around the lungs. Surgeons can ease this problem through a minor surgical procedure.
A thoracentesis (also known as a pleurocentesis or pleural tap) uses a long, thin needle to drain fluid buildup from the pleural space. It can be done in a doctor’s office with a local anesthetic. Patients usually return home an hour or two after the procedure.
To treat recurring fluid buildup, a doctor can also insert an indwelling catheter attached to a plastic bag, which allows continuous drainage when the patient is at home.
A pleurodesis drains fluid buildup and then seals the pleural space to prevent future buildup. It is performed under general anesthesia and requires a brief hospital stay. According to the American Cancer Society, about 90 percent of patients receive some relief after a pleurodesis.
Surgeries for Removing Mesothelioma Tumors
There are two major tumor-removing surgery options for pleural mesothelioma: Extrapleural pneumonectomy and pleurectomy and decortication. Both procedures are extensive and require an experienced mesothelioma doctor.
An extrapleural pneumonectomy, or EPP, removes an entire lung, the lining around the lung and parts of the diaphragm. This permanently reduces the patient’s stamina, but patients can live a long time with only one lung if they adjust their lifestyle.
This surgery is extremely invasive and comes with significant risks of complications. Recovery usually takes several months.
Pleurectomy and Decortication
A pleurectomy and decortication — also known as P/D and lung-sparing surgery — removes the pleural lining surrounding the lung and all visible tumors on the lung and chest wall. Because it leaves both lungs intact, it comes with lower risks of complications and a shorter recovery period than an extrapleural pneumonectomy.
However, a pleurectomy and decortication will not be an option if cancer has spread into the patient’s lung.
EPP vs. P/D
Pleural mesothelioma surgeons debate the pros and cons of each type of surgery. Some surgeons prefer the pleurectomy and decortication because it puts patients at less risk. Other surgeons maintain that an extrapleural pneumonectomy eliminates more cancer cells from the body.
Many mesothelioma specialists conduct both procedures, and they will not make the final decision until surgery has begun and they see exactly how far mesothelioma tumors have spread.
In 2018, doctors from Mount Sinai Hospital reported in the Journal of Surgical Oncology that patients who undergo extrapleural pneumonectomy are twice as likely to die within 30 days or experience serious complications, compared to patients who undergo a pleurectomy and decortication.
That same year, though, the European Journal of Cardio-Thoracic Surgery published a study from Belgium arguing that an extrapleural pneumonectomy can significantly extend survival, as long as patients are carefully selected.
In 2019, Japanese doctors weighed in with an article in Seminars in Thoracic and Cardiovascular Surgery. According to their treatment record, less-invasive procedures such as the pleurectomy and decortication can work just as well as an extrapleural pneumonectomy while decreasing the risk of complications.
Both procedures are usually combined with chemotherapy, but specialists also debate whether it is best to give chemotherapy before or after surgery.
Advances in Pleural Mesothelioma Surgery
Specialists constantly investigate new surgical techniques and novel therapies that can be combined with pleural mesothelioma surgery as part of a multimodal treatment plan.
In robotic surgery, the surgeon operates miniature robotic instruments by remote control and sees into the body through a tiny 3D camera.
This allows for more precise movements and a magnified view, which can significantly reduce blood loss during the procedure. Reduced blood loss means less stress on the remaining lung and a faster recovery.
The first robotic surgery to remove pleural mesothelioma tumors was performed by Dr. Farid Gharagozloo at the University of Arizona Cancer Center in 2013. In the years since, many pleural mesothelioma surgeons across the country have adopted robotic surgery techniques.
Photodynamic therapy uses light energy to kill cancer cells. Before surgery, the patient receives a photosensitizer drug that accumulates in cancer cells. During surgery, the surgeon exposes the tumor-removal site to a special wavelength of light to kill any cancer cells still in the body.
In 2018, doctors at the Abramson Cancer Center reported on their success treating 10 late-stage pleural mesothelioma patients. They combined surgery, photodynamic therapy and proton therapy, a special type of radiation therapy. This treatment combination led to a median overall survival of 30.3 months.
Top Mesothelioma Surgeons and their Cancer Centers
Across the U.S., there are specialized mesothelioma cancer centers where patients can receive expert evaluation and treatment from a thoracic surgeon.
Dr. Gharagozloo joined Florida Hospital Celebration Health in 2015. His vast experience in robotic surgery has helped the hospital improve its treatment of pleural mesothelioma patients. In fact, Gharagozloo was the first doctor to use robotic surgery to perform an extrapleural pneumonectomy on a mesothelioma patient.
Before arriving at Celebration, Gharagozloo worked at the Arizona Cancer Center in Tucson. He also served as the director of the Washington Institute of Thoracic Cardiovascular Surgery.
Dr. Flores is chief of thoracic surgery at the Mount Sinai Hospital, where he specializes in surgical procedures and techniques for mesothelioma. His concerns about the risks and loss of quality of life after removing an entire lung led to his research on lung-sparing surgery.
Dr. Cameron is a pioneer of lung-sparing surgery for early-stage pleural mesothelioma. Cameron is director of thoracic surgery at UCLA Medical Center and treats patients at the VA Greater Los Angeles Healthcare System. Cameron also serves as director of the Pacific Mesothelioma Center.
Recovering from Mesothelioma Surgery
Tumor-removing surgery may require a hospital stay of two weeks or more. For the first few days after surgery, patients may need a respirator to breathe and chest tubes to drain fluid from the lungs.
After leaving the hospital, fully recovering from surgery may take a few months.
Getting lots of rest and sleep is essential to recovery. Make sure to eat well, because the body needs adequate protein and nutrients to repair wounds and cope with potential side effects of surgery.
Managing Pain After Surgery
The most common side effect of all surgeries is pain around the incision site. After invasive surgeries, patients may feel dull, tingling discomfort or more intense pain while moving around. Work with your surgeon and a palliative care doctor to ensure you are prescribed the right types of pain medication.
Other Surgery Side Effects
Talk to your medical team about how to prepare for the potential side effects of pleural mesothelioma surgery.
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.
Nurses will teach you breathing exercises and coughing techniques to help you prevent developing pneumonia.
- Reduced Stamina
Pulmonary rehabilitation can make breathing easier for patients after aggressive lung surgery.
The body undergoes much stress during surgery and requires a lot of energy to recover. Get plenty of rest, eat enough calories and start doing light physical activity as soon as you can.
- Heart Problems
The most common cardiac side effect is an abnormal heartbeat. Other cardiac complications include inflammation, compression caused by fluid accumulation and heart attack.
Respiratory failure, air leakage, blood clotting and internal bleeding are other rare complications that must be quickly treated in a hospital.