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.

Mesothelioma treatments include chemotherapy, radiation, surgery, or a combination of these approaches. Each of these treatment approaches are different in nature and scope. Radiation uses machines to destroy cancer cells. Chemotherapy uses medication to treat cancer. Surgery is when a doctor performs an operation to remove some or all of the cancer.

Surgery in Pleural Mesothelioma

In mesothelioma treatment, surgery may be used for different reasons. First, it may be used to remove tumors and increase the length of a patient’s life. It may also be used to improve a person’s quality of life by lowering pain and symptoms. Finally, it may be used to help doctors look at a patient’s cancer and get a better idea of how extensive it is.

For malignant pleural mesothelioma (MPM), which is cancer in the lining of the lungs, surgery is used to removing tumor(s) that can be seen during the operation. Chemotherapy and radiation can sometimes be used afterwards to kill off or slow down the remaining cancer cells.

The principles of surgical management for cancer are similar for all types of solid tumors. Surgery for MPM aims at removing all the tumor that can be seen during the operation (macroscopic disease) whereas chemotherapy and radiotherapy aim to kill any remaining cancer cells locally (in the lung cavity) or in other organs (microscopic disease).” – Papaspyros, MD

Demystifying These Terms

In MPM, the doctor may remove parts of the lining around the lungs. This is called a pleurectomy. However, in some cases, the cancer has spread significantly and is unable to be completely removed. As a result, chemotherapy or radiation may be used after surgery.

Decortication is a procedure that removes a layer of fibrous tissue covering the lungs, chest wall, and diaphragm. With decortication, the goal is to remove this layer and allow the lungs to work correctly. When successful, the lung is better able to expand and deflate and the patient’s symptoms improve.

Pleurectomy with Decortication (P/D)
This procedure combines the 2 listed above. On the side of the chest with cancer, all of the lining of the chest wall (pleura) is removed. The pleura coating the lung and other organs on that same side is removed. Most importantly, the lung and diaphragm are not removed.

In the early stages of MPM, P/D can be used to try to cure the cancer. It can also be used to help symptoms when the entire tumor cannot be removed. This type of surgery can be used to help control the buildup of fluid, improve breathing, and lower pain caused by the cancer.

Debulking (or Partial Pleurectomy)
This surgery is a less extensive version of P/D. In general, less tissue is removed. The goal is to remove as much of the cancer as possible.

Extrapleural Pneumonectomy (EPP)
With EPP, the doctor removes several things, including (1) the lung on the side of the cancer; (2) the chest wall lining (pleura) on that side; (3) part of the diaphragm on that side; (4) the pericardium (the sac around the heart); and (5) nearby lymph nodes. The diaphragm and pericardium are then rebuilt with man-made materials. EPP is an extensive operation. Patients must be in good overall health with good lung function and no other serious illnesses. Many tests are done beforehand. Significant complications can occur in as many as 1 in 3 people with this operation.

For those who aren’t eligible for surgery, radiation and chemotherapy are commonly used. In addition, while surgery is often used for early stage MPM, studies are underway looking at new medications for treating patients with more advanced cases.

What Is the Best Type of Surgery for MPM?

There is no single best type of surgery for mesothelioma. Every patient is different. The choice of surgery is based on how long a patient has had cancer, what parts of the body it affects, what types of diseases or sicknesses the patient has had in the past, and many other factors.

In the past, EPP was the most common surgical approach for MPM. However, P/D, which has been studied more and more, preserves healthy lung tissue. It may also be associated with fewer problems. In the past, it was usually used for patients who were not candidates for EPP. Recent research along with the preferences of patients and doctors has led to more P/D procedures.

With MPM surgery, particularly EPP, recurrence of the cancer occurs in the vast majority of patients (around 80%). However, studies are underway to look at the addition of radiation and chemotherapy to P/D. Scientists want to see if adding these things to P/D would lower recurrence rates. At this point, data are limited, but use of all 3 procedures appears more possible with P/D than with EPP. As a result, by allowing more patients to receive combination therapy, P/D may be associated with fewer complications and living longer.

Researchers also suggest that surgical treatment such as P/D can improve quality of life. This means that it may help patients get back to their normal lives quicker. This can be particularly true in patients who have symptoms such as fatigue and shortness of breath.

Emerging data continue to show that P/D is less invasive than EPP, and is associated with better health and longer life. However, it is not right for everyone. Data from clinical studies show the potential benefits that surgery can offer for patients, particularly when treated with surgery, then chemotherapy and/or radiation.