Surgery for pleural
Surgical treatment options for mesothelioma depend on a number of things including the type of mesothelioma, how advanced the disease is, the general health and fitness of the patient and their personal preferences.
There are two approaches to surgery for patients with mesothelioma: radical surgery and palliative surgery.
It is important to remember that, unlike radical surgery many other cancers where radical surgery may offer the chance of a cure, this is not the case with mesothelioma. It is very uncommon for patients having radical surgery to gain a cure, in other words never having further problems with mesothelioma. However surgery may have an important role in improving and controlling symptoms and maintaining the quality of life in the longer term.
We are currently waiting on the results of an important trial called MARS 2 which may clarify the role of radical surgery in improving and controlling symptoms, as well as whether this surgery can also prolong life expectancy in come types of mesothelioma.
The Radical surgery in mesothelioma is called an Extended Pleurectomy/Decortication (e/PD).
The intention of e/PD is to remove all of the visible tumour. Where tests have confirmed that cancer cells have not spread elsewhere in the body, radical surgery may be suitable for some patients to help gain local control of the tumour. This, of course, cannot be guaranteed, as small deposits of cancer cells may be undetectable.
Who can have it?
e/PD is appropriate for only a small number of patients since the majority have disease that has already progressed beyond being able to be completely removed, or the person with mesothelioma may not be physically or medically fit enough for surgery. With mesothelioma, although wide margins of normal tissue around the removed cancer are difficult to achieve, the goal of local control can be achieved in some patients.
What is involved in an Extended Pleurectomy/Decortication (eP/D)
With an eP/D, both layers of the pleural lining are stripped. This includes the pleura attached to the chest wall (Parietal), and the pleural membrane attached to the lung (Visceral) is peeled off leaving the lung in place. Sections of the pericardium and diaphragm are often removed, depending on the extent of the tumour.
eP/D is a very big operation that is only suitable for patients with sufficient reserves. As the lung remains in place, and it may function better after surgery as it can often now expand more easily, recovery from surgery can be quicker than anticipated and in the longer term quality of life may be preserved or even improved.
The type of operation depends on whether the lung on the affected side will expand or not. If after drainage of the fluid around the lung (pleural effusion) the lung will expand, then the options are either the insertion of sterile talc around the lung to seal the space between the pleural linings (pleurodesis) or the removal of the bulk of the tumour (pleurectomy). Both these procedures can be performed reliably by keyhole surgery Video Assisted Thoracoscopic Surgery (VATS).
If, however, the lung is encased by tumour and cannot expand after fluid has been drained, then surgical removal of the surface layer of the lung (decortication) will be required to make it possible for the lung to expand and thereby improve the function of the lung and improve shortness of breath. It is sometimes possible to decorticate the lung by keyhole surgery (VATS), but the majority of surgeons would perform decortication by opening the chest with a large cut made around the back below the shoulder blades, between the ribs this is called a thoracotomy.
Thoracotomy and decortication is a larger procedure reserved for the younger, fitter patients. In the elderly, more infirm patient, a tunnelled, indwelling pleural catheter (TIPC) can be inserted. This is a permanent drain with a valve that empties the pleural fluid into a vacuum bottle, every few days as required. More information about TIPC can be found in the Controlling Symptoms section.
Referral for surgery
Patients can discuss the appropriateness of surgical treatment with the doctor who is currently caring for them. Not all hospitals are able to offer surgical treatment for mesothelioma. Referral to other hospitals for treatment can be done by the hospital team currently caring for the patient or the GP where this is not feasible. Mesothelioma UK can help to identify the nearest surgical unit, where this is requested.
Surgery is frequently used across the UK to gain a diagnosis and treat pleural effusion. The provision of radical and palliative surgery may vary between parts of the UK and different hospitals. However, not all thoracic surgeons in the UK have experience of radical surgery for malignant pleural Mesothelioma and opinions can differ as to the benefits. It may be necessary for patients to be referred to a specialist centre.