Mesothelioma surgery
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Mesothelioma Microchapters |
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Mesothelioma surgery On the Web |
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American Roentgen Ray Society Images of Mesothelioma surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Feham Tariq, MD [2]Parminder Dhingra, M.D. [3], Sujit Routray, M.D. [4]
Overview
The feasibility of surgery depends on the stage of mesothelioma at diagnosis.
Surgery
Surgery may be used to treat mesothelioma. Surgery is generally used along with other treatments, such as chemotherapy and radiation therapy. Surgery for mesothelioma is very specialized and is usually done by surgeons with expertise. The objective of surgery in mesothelioma is as follows:[1]
- completely remove the cancer
- Surgery that completely removes the cancer offers the best outcome for people with mesothelioma, but this treatment is often an option for only a small number of people because
- Many people with mesothelioma are not diagnosed until their cancer is advanced and has spread.
- Mesothelioma doesn’t usually grow as a single tumor, but tends to spread along nearby tissues and structures, which makes it very difficult to completely remove with surgery.
- remove as much of the tumor as possible (debulk) to help reduce pain or ease symptoms (palliative treatment).
- Debulking surgery is also known as cytoreductive surgery.
The type of surgery done depends mainly on the location of the tumor, the stage of the cancer, the subtype of mesothelioma and other factors, such as a person’s age, overall health, and the goal of surgery. Whether or not the tumor is resectable also depends on its location, the extent of the tumor, and how far it has grown into nearby tissues. The subtype of tumor also determines if it is resectable.
Preoperative Evaluation
As surgery in mesothelioma is a major operation, the patient needs to be in a good health, not have other debiliating diseases, and be able to tolerate surgery. Chemotherapy and radiation therapy are often used along with surgery, so the person also needs to be fit enough to have these additional therapies. Tests are done to make sure the person is healthy enough to have the operation and to help plan surgery include:
- Pulmonary function tests are performed to see how well the lungs are working. Good lung function is especially important for people having surgery for pleural mesothelioma.
- Heart problems can occur with major surgery such as extrapleural pneumonectomy. The problems can include atrial fibrillation and myocardial infarction. The person often has cardiac monitoring before surgery.
- Renal and liver function are also checked before surgery to make sure these organs are working properly. Knowing how well the kidneys and liver are functioning is also important if chemotherapy will be given after surgery.
Surgery for Pleural Mesothelioma
The role and extent of surgery for treating pleural mesothelioma is somewhat controversial because of the risks associated with surgery used to treat this cancer. The following procedures may be an option for people with pleural mesothelioma.[1]
Pleurectomy and Decortication
- People with early stage or localized (stage I) pleural mesothelioma may be offered a pleurectomy and decortication (P/D). During a pleurectomy and decortication, both the parietal pleura and visceral pleura are removed along with the tumor. The lung is not removed. A thoracotomy is done, in which the surgeon makes an incision through the chest wall in the side of chest. This allows the surgeon access to the chest cavity and lung. Drainage tubes are inserted so that fluid will drain from the pleural cavity and surrounding areas. This allows the lung to expand properly and helps with recovery.[1]
- A pleurectomy and decortication may be done in people who are older because there is less loss of lung function and P/D has somewhat less severe complications than an extrapleural pneumonectomy.
- For more advanced stages of pleural mesothelioma, a pleurectomy and decortication can also be done to help control fluid buildup in the chest, improve breathing and relieve symptoms, such as chest pain caused by mesothelioma. In this case, the procedure is done to relieve symptoms (palliation).[1]
Extrapleural Pneumonectomy
- People with stage I or stage II, and sometimes with stage III, pleural mesothelioma may be offered an extrapleural pneumonectomy (EPP). It is only offered to people whose mesothelioma is considered resectable. If a pleural mesothelioma has spread into the diaphragm, surgery is often not an option.[1]
- Extrapleural pneumonectomy is a major operation that removes the pleura, the entire lung, a portion of the diaphragm, and often the pericardium. To do an extrapleural pneumonectomy, the surgeon does a thoracotomy. A large incision is made through the chest wall in the side of the chest. A thoracotomy allows the surgeon the best access to the chest cavity and lung.
- The surgeon will also remove lymph nodes in the chest so they can be examined under a microscope.
- Once all of the necessary tissues have been removed, the diaphragm and pericardium are reconstructed, if needed. The surgeon reconstructs the diaphragm and pericardium using a mesh material that allows these structures to work much like they did before surgery.
- Drainage tubes are inserted into the chest to drain fluid from the pleural cavity and surrounding areas. This allows the remaining lung to expand and helps with healing.
- Extrapleural pneumonectomy is most often used for people with more extensive pleural mesothelioma.[1]
Thoracentesis
- Thoracentesis is a procedure in which a needle is inserted through the chest wall into the pleural space to drain pleural effusion. The fluid often builds up again, so a thoracentesis needs to be repeated when this happens. Sometimes a chest tube or pleural catheter is inserted to drain fluid.[1]
- Sometimes a special pleural catheter with a safety valve is placed. This device allows the person to drain excess fluid from their chest themselves.[1]
Pleurodesis
- Pleurodesis is performed to prevent fluid buildup in the pleural space and further pleural effusions. Excess pleural fluid is drained, and then drugs or chemicals, such as sterile talc, are put into the pleural space through a chest tube. Pleurodesis prevents further fluid buildup because it seals the parietal pleura and visceral pleura together so there is no longer a space between them.[1]
- Pleurodesis is the most commonly performed palliative procedure for pleural mesothelioma.[1]
Surgery for Peritoneal Mesothelioma
Surgery is not often possible for people with peritoneal mesothelioma. However, the following procedures may be an option for people with peritoneal mesothelioma who are candidates for surgery.[1]
Peritonectomy
- People with peritoneal mesothelioma may have a peritonectomy, in which the peritoneum is removed. This surgery is performed to remove all or as much of the tumor as possible. Other structures, such as part of the bowel, may also need to be removed. Many people have tumors throughout the abdomen, so it can be difficult to remove them all.[1]
Omentectomy
- Omentectomy removes the omentum, which is the layer of fatty tissue that covers the contents of the abdomen. Cancers of the peritoneum often spread to the omentum, so the omentum may also be removed for peritoneal mesothelioma.[1]
Paracentesis
- Paracentesis is a procedure in which a needle is inserted through the abdominal wall into the abdomen to drain ascites or peritoneal effusion. Sometimes a catheter is inserted to drain fluid. Fluid often builds up again, so a paracentesis needs to be repeated when this happens.[1]