Surgery for mesothelioma

Surgery is sometimes used to treat mesothelioma. It is often used along with other treatments, such as chemotherapy and radiation therapy. The type of surgery you have depends mainly on where the mesothelioma started and whether it has spread to the lymph nodes or other organs. When planning surgery, your healthcare team will also consider other factors, such as your age and your overall heath.

Mesothelioma is difficult to treat using surgery because it isn’t often a single tumour. It spreads along the surfaces of nearby organs, blood vessels and nerves. This makes it difficult to completely remove all of the cancer. Surgery is not offered for sarcomatoid cell type mesothelioma because it is a very aggressive cancer and surgery would not be helpful.

Surgery may be done for different reasons. You may have surgery to:

• remove as much of the tumour as possible (called debulking) before other treatments
• reduce pain or ease symptoms (called palliative surgery)

Most people with mesothelioma have advanced disease at the time they are diagnosed, so palliative surgery is more common.

If surgery to remove the mesothelioma is being considered as a treatment, your healthcare team will order certain tests. These are done to make sure you are healthy enough to have surgery and recover from it.

Pulmonary function tests are done to see how well your lungs are working. These tests tell the healthcare team if your other lung will be able to keep working if you have a lung removed. If your lungs aren’t healthy, you may not be able to have surgery. Find out more about pulmonary function tests.

Heart function tests are done to make sure that your heart is healthy enough to have surgery. Heart problems that may happen during surgery include an irregular heartbeat or a heart attack. Find out more about electrocardiogram (ECG) and echocardiogram, which are the 2 most common heart function tests done before surgery.

Blood chemistry tests are done to see how well your kidneys and liver are working. Find out more about blood chemistry tests.

You may not be able to have surgery for mesothelioma if you are in poor health.

The type of surgery used to treat pleural mesothelioma is somewhat controversial because of the risks that are associated with surgery. These operations remove a lot of tissues and organs from the body along with the cancer, so they can be very difficult to recover from.

The following types of surgery are used to treat pleural mesothelioma.

Extrapleural pneumonectomy removes the parietal and visceral pleura, the lung on the side where the mesothelioma started, part of the diaphragm and the lymph nodes in the chest. The sac surrounding the heart (pericardium) may also be removed.

An extrapleural pneumonectomy is done through a large cut (incision) in the side of the chest (called a thoracotomy). After all the tissue has been removed, the surgeon will use a special material to repair the diaphragm and the pericardium. Tubes will be put into the chest to drain fluid from the area where the surgery was done. This helps with healing and helps the remaining lung work properly. The tubes are removed once there is no more fluid draining from the chest.

People with stage 1 or 2 pleural mesothelioma, and some people with stage 3, may be offered an extrapleural pneumonectomy. It is only offered to people whose mesothelioma can be completely removed with surgery (is resectable). If the mesothelioma has spread into the diaphragm, surgery is not usually done.

An extrapleural pneumonectomy may have the most treatment benefits because it may remove most of the cancer. But it is a very extensive surgery that could cause a number of complications, so your healthcare team will discuss the risks and benefits with you.

Pleurectomy and decortication removes both the parietal pleura and the visceral pleura along with the mesothelioma. The lung is not removed.

A thoracotomy is used to do this type of surgery. Tubes will be put into the chest to drain fluid from the area where the surgery was done. This helps with healing and helps the remaining lung work properly. The tubes are removed once there is no more fluid draining from the chest.

This type of surgery may be offered to older people with mesothelioma because there is little or no loss of lung function and the side effects are not as serious.

In people with more advanced pleural mesothelioma, a pleurectomy and decortication may be done to control fluid buildup in the chest, improve breathing and reduce chest pain.

Palliative surgeries treat symptoms, such as pain or difficulty breathing, but they do not treat the pleural mesothelioma itself.

Debulking surgery removes as much of the mesothelioma as possible, but not as much as a pleurectomy and decortication.

Thoracentesis drains fluid or air from around the lungs using a hollow needle or tube (catheter) that is inserted through the skin into the space between the lungs and the wall of the chest (pleural cavity). Pleural mesothelioma can often cause a buildup of fluid around the lung called a pleural effusion. Thoracentesis is used to drain this fluid. It may need to be repeated if the fluid builds up again. Find out more about thoracentesis and pleural effusion.

Pleurodesis seals the parietal pleura and the visceral pleura together so there is no space in between them. It is used to prevent fluid from building up again. During the procedure, excess fluid is drained from the pleural space through a chest tube. Drugs or chemicals, most often sterile talc, are then put into the pleural space to seal them together. Pleurodesis is the most commonly used palliative procedure for pleural mesothelioma.

Surgery is usually not possible for people with peritoneal mesothelioma because the cancer has usually spread too much for it to be completely removed. Surgery is often used to relieve symptoms caused by peritoneal mesothelioma.

People with peritoneal mesothelioma may be offered debulking surgery to remove all or as much of the mesothelioma as possible. During surgery the lining of the abdomen (peritoneum) is removed. This is sometimes called a peritonectomy. Other tissues and organs may need to be removed, such as part of the bowel, the gallbladder and appendix. The layer of fatty tissue that covers the organs in the abdomen (omentum) may be removed as well. This is because peritoneal mesothelioma often spreads to the omentum.

Chemotherapy drugs may be put into the abdomen after surgery is finished and before the cut is closed. This is called intraperitoneal chemotherapy, and if the chemotherapy drugs are heated before putting them in the abdomen, it is called hyperthermic intraperitoneal chemotherapy. 

Paracentesis drains fluid from the abdominal cavity using a hollow needle or tube (catheter). Peritoneal mesothelioma often causes a buildup of fluid in the abdomen (ascites). Removing this fluid can relieve symptoms, such as abdominal swelling and shortness of breath. Because fluid often builds up again in the abdomen, paracentesis may have to be repeated. Find out more about paracentesis and ascites.

Side effects can happen with any type of treatment for mesothelioma, but everyone’s experience is different. Some people have many side effects. Other people have only a few side effects.

If you develop side effects, they can happen any time during, immediately after or a few days or weeks after surgery. Sometimes late side effects develop months or years after surgery. Most side effects will go away on their own or can be treated, but some may last a long time or become permanent.

Side effects of surgery will depend mainly on the type and site of surgery and your overall health.

Surgery for pleural mesothelioma may cause these side effects:

• rib pain
• problems breathing, shortness of breath
• a collection of pus in the chest (empyema)
• air leaking from a lung
• heart problems, such as an abnormal heartbeat or a heart attack – especially after an extrapleural pneumonectomy

Surgery for peritoneal mesothelioma may cause these side effects:

• a paralyzed bowel – the bowel stops its normal movements and food cannot move through the digestive system
• a bowel obstruction– the small intestine or colon is partly or completely blocked

Tell your healthcare team if you have these side effects or others you think might be from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Find out more about surgery and side effects of surgery. To make the decisions that are right for you, ask your healthcare team questions about surgery.