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Written by Jenna Campagna, RN

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Mesothelioma Surgery

Mesothelioma surgery paired with other therapies is the best hope to improve a patient’s survival chances. Doctors recommend different types of surgery for mesothelioma depending on where the tumors exist. Surgery isn’t curative on its own but does remove the largest percentage of tumors in the shortest amount of time.

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Important Facts About Mesothelioma Surgery

  • There are three debulking surgeries for pleural mesothelioma and one for peritoneal mesothelioma. There’s one rarely used surgery for pericardial mesothelioma.
  • The goal of surgery is to remove as much of the cancerous growth as possible. This is called “cytoreduction”, which means reducing the number of cancer cells.
  • Patients in later stages may not qualify for curative surgery but can receive pain-relief surgery to reduce symptoms.
  • Going to the top cancer centers for mesothelioma will improve the chances of a successful surgery.

Mesothelioma Surgery Options

The United States Food and Drug Administration (FDA) hasn’t approved any surgery for mesothelioma treatment. Doctors use each type when appropriate.

The three types of mesothelioma each have different surgeries. Pleural mesothelioma, the most common type of this cancer, has two aggressive surgeries intended to remove the disease. Peritoneal mesothelioma and pericardial mesothelioma each have one surgery option:

  • Pleural mesothelioma — extrapleural pneumonectomy and pleurectomy with decortication
  • Peritoneal mesothelioma — cytoreduction with HIPEC (peritonectomy)
  • Pericardial mesothelioma — Pericardiectomy

How to Get Surgery for Mesothelioma

If you’re interested in how to get surgery for removing your mesothelioma, follow these three steps:

1

Connect with an experienced mesothelioma surgeon. There are top specialists throughout the country who offer initial consultations. This meeting allows you and the surgeon to discuss your options and determine if surgery is appropriate for your case.

2

Research each surgery for mesothelioma. Pleural mesothelioma is treated by one of two surgeries: EPP or P/D, with the former removing the lung and the latter sparing it. Peritoneal mesothelioma has cytoreduction with heated intraperitoneal chemotherapy. You should also research intraoperative chemotherapy and intraoperative radiation.

3

Prepare for your upcoming surgery. If your doctor agrees that surgery is an option and you want to proceed, begin strengthening your body for the procedure. Alter your diet and exercise to improve your health. This will increase your chances of responding well to an invasive operation.

Pleural Mesothelioma Surgery

The two main methods of surgery for pleural mesothelioma are extrapleural pneumonectomy (EPP) and pleurectomy with decortication (P/D). Surgeons often prefer one or the other, even though their use depends more on the patient’s unique case. EPP removes the lung from the body. P/D removes just the pleura and possibly the diaphragm and pericardium.

The EPP versus P/D debate comes down to whether to remove the patient’s lung. Some surgeons worry about the patient’s quality of life with only one lung and prefer to not perform the EPP. Others believe removing the lung is the best chance to resect the disease fully.

Mesothelioma Extrapleural Pneumonectomy (EPP)

Extrapleural pneumonectomy was the first surgery for pleural mesothelioma. Dr. David Sugarbaker, who passed away in 2018, proposed it be used for mesothelioma. It’s called the mesothelioma lung-removal surgery.

Surgeons remove an entire lung, the lining of the lung (pleura), the lining of the heart (pericardium), and a section of the diaphragm. They add a patch of Gore-Tex breathable fabric to reconstruct the parts of the body they may have removed.

The EPP is a radical procedure and not generally suggested for late-stage patients due to the risks of removing the lung and the spread of the cancer. Dr. Sugarbaker’s 2014 study had an average survival time of 18 months. Around 14% of patients survived for five years, and 39% for two years. More than 500 patients were involved in the study.

Multimodal Treatment With Mesothelioma EPP

Mesothelioma surgery is most successful when combined with other treatment options. Patients treated with surgery alone saw average survival times of approximately one year.

In 2008, esteemed Dr. Raja Flores studied more than 300 EPP cases and saw a median survival of one year. A more recent study had a median survival of 18 months. Other studies had similar survival times, even with neoadjuvant and adjuvant chemotherapy or radiation.

Patients receive chemotherapy and radiation to help prevent future tumor growth and spread. The combination of cisplatin and pemetrexed is the FDA-approved chemotherapy for mesothelioma.

Another option is radiation before mesothelioma EPP surgery. This method is called SMART (surgery for mesothelioma after radiation therapy). Around 70% of patients survive for three years with this approach.

Mortality Rates in Mesothelioma EPP

In 1976, Dr. Eric Butchart reported a 31% mortality rate from 29 EPP surgeries. Only three patients survived for at least two years.

Mortality rates for mesothelioma EPP have improved drastically over the last few decades. Dr. Flores reported 7% in 2008, and more recent studies reported around 10% mortality rates.

In 2004, the late Dr. Sugarbaker and his colleagues reported a 3.4% mortality rate, specifically at Brigham and Women’s Hospital. Dr. Sugarbaker and his team advanced and nearly perfected the surgery.

Complications from EPP include:

  • Atrial fibrillation (irregular heart rate)
  • Deep-vein thrombosis (blood clots)
  • Acute Respiratory Distress Syndrome (fluid buildup in lung air sacs)
  • Pneumonia
  • Respiratory failure
  • Internal bleeding
  • Pulmonary embolism (blockage of a pulmonary artery)
  • Cardiac arrest
  • Kidney failure

Mesothelioma Pleurectomy with Decortication (P/D)

Pleurectomy with decortication is a lung-sparing debulking surgery. It originated as an alternative to EPP.

Not all patients can endure removal of their lung. P/D provides another option to remove most or all mesothelioma tumors while keeping both lungs intact. P/D involves the removal of the pleura and scraping tumors off the exterior of the lung. The extended P/D removes the pleura, plus part or all of the:

  • Diaphragm
  • Pericardium

A recent study reported doctors prefer P/D over EPP for malignant pleural mesothelioma. Mount Sinai Cancer Center researchers found 81% of surgery cases from 2007-2017 used P/D, while only 19% used EPP.

P/D survival with no other therapy is 11-21 months, according to a study at Memorial Sloan Kettering Cancer Center. When combined with chemotherapy or other treatments, average survival is up to 32 months. Two studies reported a 32-month survival time for regular P/D or extended P/D.

Multimodal Treatment with Mesothelioma P/D

Chemotherapy is often used after mesothelioma P/D surgery. The chemotherapy regimen is pemetrexed and either cisplatin or carboplatin.

Many specialists avoid radiation surgery after P/D, although some rely on the highly targeted intensity-modulated radiation therapy. Intraoperative radiation therapy is another option. This method uses radiation during the surgical procedure.

Mortality Rates in Mesothelioma P/D

Mortality rates for P/D are lower than EPP. The rates were lower for all four studies included in a 2017 Annals of Translational Medicine report.

Dr. Flores’ study from 2008 had a 4% mortality rate for P/D. Other studies have been as low as 2% mortality.

Complications from P/D include:

  • Pneumothorax (air leaking out of the lung)
  • Pneumonia
  • Respiratory failure
  • Pulmonary embolism
  • Blood clots

Peritoneal Mesothelioma Surgery

There’s one aggressive surgery for peritoneal mesothelioma: cytoreduction, which involves a peritonectomy (removal of the peritoneum) and “debulking.”

Doctors pair cytoreduction with “heated intraperitoneal chemotherapy.” This is an intraoperative chemotherapy performed right after cytoreduction.

Mesothelioma Cytoreduction

Cytoreduction is a peritonectomy and debulking, which is the manual removal of all visible tumors in the abdomen.

The peritoneum is where peritoneal mesothelioma forms. It’s a thin layer of tissue that encompasses the abdominal cavity. The peritonectomy removes most of the tumors from the body.

Patients are placed under general anesthesia, and the surgery lasts about 10 hours. During this time, a surgeon removes as much of the visible tumor as possible by removing the peritoneum. The procedure is lengthy due to the debulking process, which is a meticulous exercise but required to prevent recurrence.

Hyperthermic Intraoperative Chemotherapy (HIPEC)

HIPEC is a heated chemotherapy bath in the abdominal cavity. Doctors pour the liquid chemotherapy drugs into the abdomen and rock the patients back and forth to bathe the entire area. HIPEC usually lasts 1-2 hours, depending on the cancer center, and starts quickly after debulking ends.

A study in 2019 reported a median survival of 50 months following cytoreduction with HIPEC. Another study around the same time, conducted at Wake Forest Baptist Cancer Center, reported a median survival of 40 months:

  • One-year survival rate was 77%
  • Five-year survival rate was 30%

A third study of 211 patients revealed a median survival of 38 months and a 41% five-year survival rate.

Patients also report improved quality of life after cytoreduction with HIPEC. Their physical pain decreased while emotional well-being improved.

Mortality Rates With Cytoreduction and HIPEC

The mortality rate from cytoreduction with HIPEC is very low. A 2019 study on the JAMA Network reported a 1.1% mortality among 1,822 patients.

Another study of 405 patients revealed just a 2% perioperative mortality rate. Nearly half of patients experienced complications, but around 20% had grades 3 or 4 complications (more severe).

Some of the mild or severe complications include:

  • Small bowel perforations
  • Anastomotic leaks
  • Abdominal abscesses
  • Pancreatic fistulas
  • Urinary tract infections

Pericardial Mesothelioma Surgery

Pericardial mesothelioma is the rarest form of mesothelioma, and a pericardiectomy is the only surgical option. The pericardiectomy removes the lining of the heart, called the pericardium. This lining is not essential for normal heart functioning.

Doctors use Gore-tex patches to re-envelop the heart with an artificial pericardium. The Cleveland Clinic website states inpatient recovery usually lasts 5-7 days, and full recovery takes 6-8 weeks.

Palliative Mesothelioma Surgery

Palliative surgeries are available to reduce symptoms, such as pressure from fluid buildup. This symptom in particular occurs almost always for mesothelioma and prevents the lungs, abdomen or heart to expand and contract normally.

The fluid buildup leads to pain for patients. There are several palliative surgical options for these patients.

Mesothelioma Palliative Surgery Options

  • Pleurodesis – Pleurodesis closes the pleural space and limits fluid buildup in the pleura (pleural effusions).
  • Thoracentesis – This procedure drains fluid buildup in the lungs. Doctors use a needle to drain fluid, but they do not close the pleural space.
  • Paracentesis – This procedure drains fluid from the abdomen. This fluid buildup is known as ascites.
  • Pericardiocentesis – This procedure drains fluid from the sac that lines the heart (pericardium). Doctors drain fluid from the pericardium with a needle.

When to Get Mesothelioma Surgery

It’s important to get mesothelioma surgery right away. Duke University researchers analyzed cases in the National Cancer Database. They compared cases where surgery was the first treatment used versus the second, usually after neoadjuvant chemotherapy.

Researchers found that mesothelioma chemotherapy before surgery led to higher rates of postoperative mortality. The average survival rates were:

  • 19 months for the group having surgery first
  • 16 months for the group having chemotherapy first and surgery second

Other research shows massive benefit to radiation before surgery. SMART for mesothelioma (surgery for mesothelioma after radiation therapy) has improved survival times by multiple years for patients with the epithelioid cell type. Radiation slows the growth of tumors and makes removal during surgery easier.

Finding a Mesothelioma Surgeon

Each mesothelioma surgeon specializes in one or two of the surgeries described above. For instance, thoracic surgeons focus on pleural mesothelioma surgeries, whereas surgical oncologists focus on peritoneal mesothelioma surgery.

A few of the top mesothelioma surgeons in the United States are:

Our team can help you contact any of these mesothelioma surgeons or others in the country. We can also help you choose a surgeon at a renowned cancer center and schedule a consultation for free. Contact our patient advocates for further assistance with scheduling your mesothelioma surgery.

Common Questions About Surgery for Mesothelioma

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Can mesothelioma be removed through surgery?

Surgery can remove a large bulk of the mesothelioma — sometimes all of it — but patients often have a few tumors left behind. Mesothelioma is a difficult cancer to treat, largely due to how it grows and spreads. It’s not one ever-growing tumor, but rather many separate microscopic tumors.

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How does surgery help treat mesothelioma?

Surgery is the most effective course of action to treat mesothelioma. It addresses the largest quantity of the disease in the shortest amount of time. Surgery negates the disease’s progress and usually eliminates the majority of the tumors. The result is stories of patients alive multiple years, sometimes even a decade, later.

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What is the difference between EPP and P/D for mesothelioma?

EPP, which is the abbreviation for extrapleural pneumonectomy, requires removing the affected lung in addition to the pleura, part of the diaphragm and possibly the lining of the heart. P/D, which is short for pleurectomy with decortication, leaves both lungs intact.

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What surgery is used for peritoneal mesothelioma?

Cytoreduction with HIPEC for peritoneal mesothelioma is the best operation for extending patients’ lives. The surgery involves removing the peritoneum (where this cancer forms) and “debulking,” which is the meticulous removal of all visible tumors. Following surgery, doctors wash the abdomen with a heated chemotherapy.

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What pain-relief surgeries can help for mesothelioma?

Pain-relief surgeries can minimize some of the uncomfortable mesothelioma symptoms, such as fluid in the chest or stomach. A pleurodesis, for instance, closes the pleura and limits fluid buildup near the chest. Two other procedures drain excess fluid from the body:

  • Thoracentesis (pleural mesothelioma)
  • Paracentesis (peritoneal mesothelioma)
  • Pericardiocentesis (pericardial mesothelioma)
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Who are some of the top surgeons for mesothelioma?

Finding an experienced mesothelioma surgeon is imperative. You’ll want to trust your life in the hands of someone who has safely performed these operations. A few of the top surgeons for mesothelioma are:

Sources & Author

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About the Writer, Jenna Campagna, RN

Jenna Campagna is a registered nurse and patient advocate who is passionate about helping mesothelioma patients navigate their health care. She has over seven years of experience working with patients diagnosed with rare diseases including mesothelioma. Jenna is also a member of the Academy of Oncology Nurse & Patient Navigators and her goal is to connect patients to top mesothelioma specialists, treatment facilities, and clinical trials. Through her writing, she aims to simplify the complicated journey through mesothelioma by offering helpful tips and advice.