Surgery is a definitive step in the treatment of mesothelioma. When physicians diagnose a case of mesothelioma, they look at a variety of symptoms and issues and assign a stage to that particular case. One of the principal questions when defining the stage to which malignant mesothelioma has developed is whether or not it is still at the point where surgery may be possible to remove some or all of the malignant tissue. Implicit in this decision is the assumption that there is the possibility of removing enough of the cancer to put the disease into remission or at least slow it significantly.
A decision that surgery is not a viable option generally means that the disease has advanced beyond the stage where major interference can slow its growth, or that the patient's health is so poor that surgery could have a dangerous impact. At that point a palliative care focus takes over, with the goal of slowing the disease through the use of chemotherapy and making the patient as comfortable as possible while the cancer continues its advance to the inevitable conclusion.
There are three principal types of mesothelioma: pleural, peritoneal and pericardial. There are differing surgical treatments for each although for all of them the goal is to remove, or resect, or "debulk" as much of the malignant tissue as possible. There are also certain types of chemotherapy and/or radiation therapy that are conducted during the course of surgery which serve as part of the therapeutic treatment.
Pleural Mesothelioma Surgery
Pleural mesothelioma develops in the pleura, which is the membrane that covers the exterior of the lungs and that lines the chest cavity wall opposite the lungs. It is the most common form of mesothelioma, representing about 70% of all diagnoses. In the early stage of pleural mesothelioma the most common surgical procedure is the pleurectomy and decortication, which is the removal of the pleura – sometimes just the diseased portion of the membrane, and sometimes all of it.
If the cancer has become diffuse – that is, developed into multiple tumors across the surface of the pleura, an extrapleural pneumonectomy may be performed. This procedure involves the removal of the pleura and removal of some or the entire lung that is on the same side of the body where the mesothelioma has developed. Pleural mesothelioma always develops on one side or the body or the other, usually on the right side of the body.
There is some debate among surgeons about the relative value of these two procedures in relation to one another, but there is no question that radical surgery to treat pleural mesothelioma is instrumental in an aggressive, curative approach to the disease.
Peritoneal Mesothelioma Surgery
Peritoneal mesothelioma develops in the peritoneum, which is the membrane that lines the abdominal cavity wall. It occurs in twenty to twenty five percent of all mesothelioma diagnoses – perhaps 500 cases per year in the United States. As with pleural mesothelioma, the goal is to remove the malignant tissue in the peritoneal membrane and any adjacent evidence of malignant growth. This particular form of mesothelioma may spread fairly quickly to lymph nodes and eventually may find its way to the lower intestine, causing the development of malignancy there.
The principal operation is the peritonectomy, or removal of the peritoneum. Peritoneal mesothelioma often works its way into the diaphragm, and accordingly some surgeons perform resection of portions of this membrane as well. The most aggressive treatments remove any evidence of diseased tissue in the lower colon as well.
Pericardial Mesothelioma Surgery
Pericardial mesothelioma is extremely rare. The disease attacks the sac or membrane surrounding the heart referred to as the pericardium. When this membrane begins to thicken and harden as mesothelioma develops, it can put a dangerous amount of pressure on the heart. Pericardial surgery may be a necessity not only to for therapeutic purposes but to remove the danger of cardiovascular pressure which can cause serious heart problems.
Treatment of cardiovascular constriction from this disease is a delicate business for surgeons. Some feel that surgery under the best of circumstances isn't enough. Removal of the tumor and temporary relief of the constriction must be accompanied by the types of multimodal therapy employed with pleural and peritoneal mesothelioma, but it is a more urgent issue with this membrane surrounding the heart.
Therapy in Conjunction with Surgery
One of the more aggressive forms of treatment that has been developed for use during and after mesothelioma surgery is hyperthermic chemotherapy. Intrapleural hyperthermic chemotherapy is delivered directly to the surgical site and any adjacent diseased tissue, often on the operating table. Hyperthermic means the chemotherapy drugs are heated to make them more effective. Intraperitoneal chemotherapy is the same type of procedure. Following the surgery the direct application of chemotherapy drugs is continued through the use of a shunt or tube that is installed during the surgical procedure. Some physicians have had impressive results with this aggressive combination of surgery and targeted chemotherapy.
Palliative Mesothelioma Surgery
Thoracentesis is the extraction of fluid from the pleural cavity through the use of a needle inserted directly into the chest. Pleural effusion is a common symptom of mesothelioma: it is the accumulation of excess fluid alongside and below the affected lung. It can lead to painful pressure on the lungs as well as a reduction in breathing capacity. Both thoracentesis and the pleurectomy may be performed as palliative measures to relieve this difficult symptom.
A more radical approach to treating pleural effusion is pleurodesis, a procedure that closes off the space between the inner and outer pleural membranes surrounding the lungs. This process eliminates the possibility of continued pleural effusion by eliminating the pleural cavity. Pleurodesis involves filling the space between the two membranes with talc, which creates filler that bonds them together.
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- Options for Malignant Pleural Mesothelioma, OncoLog, Anderson Cancer Center ,University of Texas, http://www2.mdanderson.org/depts/oncolog/articles/08/11-nov/11-08-1.html
- Treatment of Peritoneal Mesothelioma, Sugarbaker Oncology Associates, http://www.surgicaloncology.com/meso.htm
- Primary Pericardial Mesothelioma, PubMed, National Institutes of Health, http://www.ncbi.nlm.nih.gov/pubmed/12194802
- Malignant Peritoneal Mesothelioma Undergoing Surgical Debulking and Intraperitoneal Chemotherapy, Journal of Clinical Oncology, Feldman et al, December 2003, http://www.jco.ascopubs.org/cgi/content/full/21/24/4560
- Pleurodesis for Malignant Pleural Effusions, PubMed, National Institutes of Health, http://www.ncbi.nlm.nih.gov/pubmed/14973997