Surgery is one of the major therapeutic modalities used in the treatment of mesothelioma. There are a number of procedures available and the doctor’s decision on which to perform will be based on each patient’s individual presentation. Important factors to be considered will include the overall treatment strategy, the disease’s histology, location and stage, as well as the patient’s general health and performance status. Improvements in surgical techniques and post-operative treatments have resulted in a higher “success” rate for many of these procedures, as well as a major reduction in perioperative and postoperative mortality rates. However, serious complications do still occur, so the decision to perform extensive surgery should always be very clearly considered.
Surgery – Surgical Strategies
There are two major surgical strategies employed in the management of this cancer: palliative surgeries and surgeries with curative intent. Palliative surgeries are procedures that treat particular symptoms of cancer without aggressively treating the disease itself. These surgeries run from low-impact, supportive care of the disease to aggressive attempts at individual symptom control (even though the underlying disease itself won’t be treated aggressively).
The goal of the surgeries with curative intent is to remove as much of the malignancy as possible. Ideally, this would mean that all of the cancer would be removed, but the disease’s complex growth pattern makes complete removal a very difficult task. Unlike other forms of cancer that present as individually-identifiable tumors with clear boundaries between the tumor and surrounding tissues, mesothelioma presents as a diffuse malignancy that spreads throughout a surface area. It generally appears as a sheath-like layer of malignant tissue made up by a large number of individual tumors, too numerous to individually remove. The boundaries between the malignant area(s) and the surrounding healthy tissues are often indistinct, which can complicate the decision on where to begin the extraction, as well as obscure the true extent of infiltration. This means that occult disease may remain after resection. Occult disease refers to microscopic cancer cells that are hidden or too small to be seen during surgery or post-operative analysis, but which are alive and still able to grow. When occult disease is present, the cancer will continue to grow and to return unless some type of post-surgical treatment is attempted to eradicate these cells.
In light of this issue, oncologists have concluded that surgery is rarely effective as a single modality therapy and that it must be combined with other therapeutic modalities to maximize patient survival time. The goal of surgery, then, is to achieve a macroscopically-complete resection, which refers to the removal of all visible tumor cells, and then adjuvant therapies will be used to treat the potential for occult disease.
Surgery – Surgeries with Curative Intent
There are two surgeries attempted with curative intent for the treatment of pleural mesothelioma: pleurectomy-decortication and extrapleural pneumonectomy. They are highly-invasive procedures characterized by extensive amounts of tissue resection and are properly considered radical surgery—a term used to describe procedures that require significantly invasive action. Because this cancer is not yet curable, these procedures are sometimes called life-extending procedures.
- Extrapleural Pneumonectomy
- An extrapleural pneumonectomy features the removal of the parietal pleura, the diaphragm and pericardium, as well as the entire lung on the affected side. For patients in all but the earliest stages of the disease, an EPP is generally the best procedure to achieve a macroscopically-complete resection
- A pleurectomy/decortication is a surgical procedure where the parietal pleura, the visceral pleura, and possibly tissue from the chest wall, diaphragm and pericardium are all removed. The lung on the affected side, however, is left in its place.
Surgery – Palliative Surgeries
There are a number of palliative surgeries available for treatment and a patient’s eligibility for them will be based on his or her overall health and performance status.
- Debulking Pleurectomy
- A debulking pleurectomy is a surgical procedure that attempts to remove as much of the cancer from the parietal pleura as possible. It is performed to decrease the dyspnea associated with heavy tumor burden and can be used in conjunction with pleurodesis to increase patient quality-of-life.
- Decortication of the Lung
- A decortication of the lung is a surgical procedure to remove the visceral pleura from lung. It is performed when the lung is constricted and unable to fully expand due to tumor infiltration of the visceral pleura. It can also be used in conjunction with pleurodesis to increase patient quality-of-life.
- Pleural Catheters and Pleuroperitoneal Shunts
- Implanted pleural catheters and pleuroperitoneal shunts can offer effective palliation for patients who suffer from recurrent pleural effusions and other fluid buildups. Long-term use of these options is generally employed only for those with late stage disease who are not amenable to other treatment options.
- A pleurodesis is a procedure that fuses together the parietal pleura and the visceral pleura, obliterating the space between them. It is the most commonly-performed palliative procedure and is done to prevent fluid build-up in the pleural space and the recurrence of pleural effusions.
Surgery – Techniques
Most surgeries that are performed for mesothelioma are completed by physicians trained as thoracic surgeons, that is, physicians who are experts in surgeries performed in the chest area, whose medical name is the thorax. Our chests contain two of our most vital organs—the heart and the lungs—so surgeries performed in the area require great skill and careful treatment, as well as excellent post-operative procedures that can maximize recovery, while attempting to minimize complications. One of the most important factors to achieving these goals is the surgical technique used for entry into the chest.
Two major techniques for entry are currently employed in most thoracic surgeries: thoracotomy and video-assisted thoracic surgery (VATS). To learn more about these procedures, please read through the summaries below and follow the “Learn More” link for greater background detail.
- Thoracotomy is a surgical procedure where a large incision is made to the chest so open surgery can be performed. It is a highly invasive technique, but is necessary for the completion of the curative surgeries.
- Video-Assisted Thoracic Surgery (VATS)
- Video-assisted thoracic surgery (VATS) is a minimally-invasive surgical technique that uses video imaging to guide the surgeon. VATS has replaced thoracotomy for a number of procedures, as it allows the same or similar treatments, but accomplishes them in a much less invasive manner.