Treatment Options
Surgery
SURGICAL PROCEDURES FOR PLEURAL MESOTHELIOMA
For patients whose pleural mesothelioma is diagnosed at Stage I or II, surgery is usually recommended. The more common mesothelioma surgical procedure is a pleurectomy/decortication (P/D), in which the surgeon removes the lining of the chest and the lung. This procedure removes much of tumor mass, reducing the painful compression of the lungs and other organs. It also allows access by chemotherapeutic agents to what remains of the tumor, retarding its growth.
Heated chemical perfusion, a newer variant of chemotherapy for pleural mesothelioma is performed in the operating room at the time of surgery. Chemotherapy medications heated to between 40 and 48°C (104-118°F) are perfused directly into the abdomen after the tumor has been debulked, that is, as much as possible of it removed. This procedure has been found to be effective in retarding tumor growth and extending survival times.
If the tumor has spread into the lung and other tissues, the surgeon may elect to do the more complex extrapleural pneumonectomy (EPP), in which the lung, much of the chest lining, and the pericardium, the tissue surrounding the heart are removed.
Although the EPP is a highly invasive procedure with significant risk of complication, some studies suggest that it offers mesothelioma patients improved breathing and mobility, and a better quality of life. For some, particularly whose mesothelioma has been diagnosed at an early stage, this surgery may also slow the progress of the disease.
Both of these procedures are major surgery, and require that a patient be in good health, and have a healthy heart and second lung. To tolerate the chemotherapy, the patient must also have a healthy liver and kidney. Age and general health are also considered in making a decision to proceed with surgery. A surgeon carefully evaluates a patient's illness and health status before recommending a plan of treatment.
SURGICAL PROCEDURES FOR PERITONEAL MESOTHELIOMA
The goal of surgery for peritoneal mesothelioma is the same as for pleural mesothelioma: to reduce the tumor mass, and allow chemotherapy the greatest access to what remains of it.
The abdomen is easier for the surgeon to enter than the chest cavity, but it is also filled with vital organs, all of which are highly fragile, and the surgery must proceed with great care.
Within the abdominal cavity, there is more surface area of peritoneum, the tissue where mesothelioma grows, than in the chest cavity. The parietal peritoneum covers the interior walls of the abdominal cavity, and the visceral peritoneum covers each of the abdominal organs, and also functions as the outer layer of the intestinal tract. The mesothelioma can be growing on any of these surfaces. The peritoneal membranes support several major blood vessels that supply abdominal organs, and the membranes themselves loop and fold around the organs, making it impossible to remove the entire tumor without damaging the organs.
The strategy for treating peritoneal mesothelioma relies on the fact that multiple surgeries are more successfully tolerated in the abdomen than in the chest cavity. The treatment plan may involve a series of surgical procedures, in which aggressive debulking removes as much tumor as possible. Each successive surgery also allows the surgeon to inspect the area and monitor the progress of the tumor and the effects of chemotherapy.
Chemotherapy is often administered at the time of surgery. One innovative treatment is heated chemoperfusion, in which chemotherapy chemicals heated to between 40 and 48°C (104-118°F) are perfused directly into the abdomen in the operating room after the tumor has been debulked.
Photodynamic therapy, treatment with drugs that become active when exposed to light, has also been used with some success.
A number of cancer centers have developed a protocol for peritoneal mesothelioma that prescribes several courses of surgery within a specified time period, combined with chemotherapy, radiation or other treatments either during or after the surgeries. This approach has increased some peritoneal mesothelioma patients' survival to over seven years post diagnosis.
RISKS AND SIDE-EFFECTS OF MESOTHELIOMA SURGICAL PROCEDURES
Surgical interventions for mesothelioma are major procedures, with serious possible complications, which include infections, bleeding in the chest cavity, pneumonia developing in the remaining lung, or fluid leaks into the chest cavity or bronchi. P/D risks the possibility of developing air leaks when the pleural lining is removed. EPP risks stressing the heart when the pericardium is removed.
The decision about whether to proceed with mesothelioma surgical procedures is an individual one, which the patient should discuss with his doctors, and with family members, weighing the risks and possible side effects against the probable outcome if no intervention is made. When these procedures are performed on appropriate patients by experienced surgeons and followed by expert nursing and follow-up care, risks are reduced. For appropriate patients surgery offers the prospect of increased comfort and improved response to chemotherapy.