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Surgery is the type of traditional mesothelioma treatment.
Major surgery for people with mesothelioma has not always been thought a good idea by surgeons. This is because surgery cannot cure the disease. And because many people with mesothelioma are not fit enough to get through a very large operation. But the point of surgery in mesothelioma is to slow the cancer down, rather than cure it.
Before any surgery is considered for the treatment of malignant mesothelioma, your overall health has to be evaluated. Tests are done to make sure the cancer has not spread to distant sites and to evaluate how well your lungs and heart are functioning. Lung tests look for any signs of lung damage from tobacco or from other diseases, including asthma and chronic obstructive pulmonary disease (COPD). These tests determine how risky surgery would be, especially if a lung needs to be removed.
Aggressive surgery — A procedure called extrapleural pneumonectomy involves removal of the pleura, the lung, the diaphragm and the pericardium. The intent of this very aggressive, complicated surgery is to remove as much of the tumor as possible. Not all centers will do this procedure because it is so complex and because it carries a high risk of death within 30 days after surgery. This procedure typically is done only in younger patients who are in good overall health with stage I disease. Patients are evaluated carefully to determine their ability to tolerate the surgery.
Palliative procedures — When malignant mesothelioma is advanced, palliative procedures can be done to relieve or control symptoms such as breathlessness, which are caused by fluid or by the tumor pressing on the lung or other organs. These procedures do not cure the disease.
The operation that can be done to remove mesothelioma is called a extrapleural pneumonectomy (EPP). This means removing the lung and the lining of the chest cavity (the pleura) on the affected side. It may help people to live more comfortably for longer. But this has to be tested because, on the other hand, it could mean that having such major surgery means people die sooner than they would have.
Curative surgery is offered if you are in otherwise good health and the tumor is thought to be localized and can be completely removed. Unfortunately, the cancer cells tend to spread into the chest wall, around the heart, over nerves, and the diaphragm. It is often difficult to detect this spread. Because of this, doctors are not clear on the exact role of surgery. It is not likely to cure you, but may extend your lives.
A thoracentesis, where fluid in the chest is removed by placing a needle into the chest cavity, may be done to make a patient more comfortable. Sometimes talc or drugs that cause scarring may be injected into the chest cavity to try to prevent the fluid from returning. These techniques are successful in controlling the fluid, at least temporarily, in as many as 90% of patients. Because pleural fluid can compress the lung and cause shortness of breath, these procedures can help you breathe more easily, however, they do not cure the cancer.
In the case of peritoneal mesothelioma, a needle may be inserted into the abdomen to drain the fluid. Similarly, a needle inserted into the pericardium (sac around the heart) can drain pericardial fluid and help relieve circulatory problems. Sometimes the cancer cells spread along the needle path, and a tumor nodule may form under the skin of that area. This concern should not prevent fluid removal, though.
Types of mesothelioma surgery:
Pleurodesis is used to prevent the build-up of fluid in the lungs if this is a recurring problem. Keyhole surgery is usually used, involving three small cuts to the chest to enable slender instruments to be used, guided by a tiny camera. In the operation, some sterile talc is inserted through a small tube and this sticks the layers of the pleural membrane together, to try to prevent any further fluid collecting. This may be done under local anaesthetic when fluid is drained, but it usually requires a few days of recovery in hospital. Alternatively, it may be done by the surgeon carrying out a surgical biopsy.
Pleurectomy/decortication is usually a palliative (relieves symptoms without curing the cancer) procedure in cases where the entire tumor cannot be removed. It involves removing the pleura, where the majority of the tumor is located. It effectively controls fluid accumulation and may decrease pain caused by the cancer.
Pleurectomy with decortication is a more limited procedure and requires less cardiorespiratory reserve. It involves dissection of the parietal pleura, incision of the parietal pleura, and decortication of the visceral pleura followed by reconstruction. It has a morbidity rate of 25% and a mortality rate of 2%. It is a difficult procedure because the tumor encases the whole pleura; the local recurrence rate is high.
The postoperative care centers on analgesia, pulmonary toilet, chest tube care, and ambulation. A pleurectomy may result in some operative blood loss and a large air leak early on. The chest tube output and the air leak usually decrease in the first few postoperative days. Patient-controlled analgesia or, preferably, epidural analgesia is used to control incisional pain. Adequate analgesia facilitates ambulation and pulmonary toilet. Incentive spirometry is important in keeping the lung expanded and avoiding atelectasis. Keeping the lung fully expanded is also necessary to decrease the bleeding from the raw areas.
A pneumonectomy is the surgical removal of an entire lung and is usually performed as a cancer treatment. There are two types of pneumonectomy:
1) traditional pneumonectomy, in which only the diseased lung is removed and;
2) extrapleural pneumonectomy (sometimes also called a pleuropneumonectomy) in which the lung is removed as well as areas of the diaphragm, and the covering of the heart.
The pneumonectomy used in cases of malignant mesothelioma. Malignant mesothelioma is a cancer of the pleura (the membrane lining the lungs) and therefore the pneumonectomy required to treat this disease, must remove not only the diseased lung, but a portion of the pericardium (the membrane covering the heart), part of the diaphragm and the parietal pleura (the membrane lining the chest cavity) on the same side of the chest. This procedure is called a extrapleural pneumonectomy.
Within the medical community there is a debate over the effectiveness of this surgery. The surgery itself is dangerous with nearly 5 to 10% of patients not surviving. However, new procedures have improved these odds in recent years. Advocates of the surgery, including an outspoken doctor in Boston believe it is the most effective way to treat mesothelioma. They point to 3 and 4 year survival rates in many patients who have had sucessful surgeries. Other doctors are not so sure and argue that this invasve procedure is not worth the risks, especially in older patients.
An extrapleural pneumonectomy is considered the best surgical option when a tumor is located in the middle of the lung and involves a significant portion of the pulmonary artery or veins. However, because the surgery is risky and diminishes half of a patient's breathing capacity surgeons usually regard it as a last option and will usually first consider a pleurectomy. A Pleurectomy is a more complicated procedure, but is lung sparing involving only the removal of the pleura. Which treatment is recommended depends on many factors, including the stage of the tumor.
Overall it is unclear if extra-pleural pneumonectomy provides significantly greater benefits than pleurectomy, and if either is significantly more effective than non-surgical options (there is debate).
Extrapleural pneumonectomy is a far more extensive operation and is most often used in cases of localized mesothelioma, when the surgeon thinks a cure is possible..It is a difficult operation to do and is done only by surgeons in large specialized medical centers. It involves removing the pleura, diaphragm, pericardium, and the whole lung on the side of the tumor. You must be in overall good health with no other serious illnesses in order to tolerate the large operation. This operation attempts to remove all or most of the cancer and some surrounding tissues as well.
Surgical treatment of peritoneal mesothelioma is often done either to help relieve symptoms or to attempt to remove the tumor from the wall of the abdomen and other digestive organs. As with pleural mesothelioma, these tumors are often too extensive to remove completely. Similar operations can be done to remove a mesothelioma from the pericardium (the sac around the heart).
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