Straight Talk about Mesothelioma, a blog series created by Michael T. Milano, M.D., Ph.D., a radiation oncology specialist, as a resource for mesothelioma patients and their loved ones.

Once the diagnosis of mesothelioma is made, the next step is to formally stage the disease. Staging is a term doctors use to determine the extent of disease spread. Before any type of treatment can be offered, staging must be done. For example, if a patient has mesothelioma which has metastasized (spread), their stage will be high, and surgery will be of no benefit. Instead, this patient may be offered chemotherapy.

Surgery is usually offered to mesothelioma patients with resectable early stage disease. “Resectable” means that the cancer is able to be removed completely. In some cases, palliative surgery may be done to relieve symptoms.

An individual must be physically fit in order to undergo surgery. Hence, prior to surgery all patients undergo extensive evaluation of the heart and lungs to determine if they will be able to withstand the surgical procedure.

There are 2 surgical procedures commonly used for the management of mesothelioma: 1) pleurectomy and 2) extra-pleural pneumonectomy. Pleurectomy, also sometimes referred to as “decortication,” essentially means removing the entire lining of the pleura that surrounds the lungs, heart, and diaphragm. An extra-pleural pneumonectomy is a more radical procedure and involves removing the entire lung in addition to the pleura.

What Does Pleurectomy Involve?

The goal of pleurectomy is to remove the pleura without resecting the lung. Because the procedure is invasive, it sometimes requires patients receiving a blood transfusion during or after surgery. A pleurectomy can be long and technically challenging procedure for the surgeon because the mesothelioma cancer can often be “stuck” to a person’s chest cavity and lungs.

The first step in a pleurectomy procedure is to make a large incision underneath the arm pit. Pleurectomy is offered to patients who are expected to tolerate this procedure, but whose heart function and/or lung reserve are limited such that they could not likely withstand a more complex and invasive procedure. Despite being a relatively aggressive surgery, the likelihood of local recurrence after pleurectomy is quite high, with most recurrences occurring within 2-3 months after surgery. Thus, the more aggressive extra-pleural pneumonectomy (described below) is generally offered to those patients whose overall health is good and whose extent of disease is relatively limited (i.e. early stage).

What Does Extra-Pleural Pneumonectomy Involve?

Extra pleural pneumonectomy is a much more complex and extensive procedure than pleurectomy. It also carries a much higher risk of death after surgery. The procedure requires removal of the patient’s entire right or left lung plus all of the pleura that surrounds the diaphragm, chest wall, and heart (pericardium). The rate of recurrence after extra-pleural pneumonectomy is much lower than the rate after pleurectomy, because all of the visible tumor is essentially removed.

If, during this procedure, there is any suspicion by the surgeon that some tumor is left behind, the patient may be offered radiation therapy after the procedure is finished.

Recovery after Surgery: What One Can Expect

After either procedure, patients will remain in the intensive care unit for several days. Because of the large incision made on the side of the chest, there is moderate to severe pain and continuous pain medications are often required for 5-7 days. Recovery after either procedure is slow. Chest x-rays are done every day for the next several days to ensure that there are no complications. Patients do undergo chest physical therapy and are regularly treated by respiratory therapists to help them cough and take deep breaths.

Patients will usually remain in a hospital for 5-14 days.

Complications after Surgery May Occur

Both procedures are associated with a number of complications including inability to breathe, chest pain, and respiratory failure requiring assistance from a breathing machine, pneumonia, bleeding, and infection. Because many mesothelioma patients are already weakened from such an invasive surgery, tolerating any side-effects after such surgeries can be extremely difficult. As such, one’s hospital stay might increase beyond 2 or 3 weeks, should such complications occur.

What’s the Current Status of Surgery for Mesothelioma Patients?

Today, most cancer doctors will recommend chemotherapy after surgery to decrease the rate of recurrence of mesothelioma. Previous studies have shown that when surgery is performed without adding chemotherapy afterwards, there is a greater risk of cancer recurrence within a few months.

Based upon recent data, surgeons have become more selective in who they offer extra pleural pneumonectomy. In addition to the surgeon accounting for the overall patient health and stage of disease, the type of mesothelioma (as it appears under a microscope) is becoming a factor in selecting patients for surgery.

The hope is that, as our studies become more and more advanced, doctors will be able to make well-informed decisions as to what the best course of action is for patients stricken by mesothelioma. Above all, the doctor’s job is to help his or her patient increase their survival and quality of life – and these 2 procedures for mesothelioma are good options to have at their disposal.