Surgery

Diagnostic Procedures

As previously mentioned in the "Symptoms" section of this website, a diagnosis of mesothelioma from fluid is many times inconclusive. Given this fact, diagnostic surgery becomes a necessary next step in confirming and staging mesothelioma.

Thoracoscopy enables a physician to evaluate the pleural cavity and to conduct multiple tissue biopsies under direct vision. In up to 98% of cases, a definitive diagnosis can be obtained. Often, chemical pleurodesis aimed at relieving the accumulation of fluid in the intrapleural space, can be accomplished during the same procedure. It is also possible to gauge the extent of the tumor, and make a determination of surgical resectability. While less invasive than an open biopsy, it can only be performed on patients where tumor has not obliterated the pleural space.

VATS, or video-assisted thoracic surgery is an alternative to thoracoscopy, although because of its more invasive nature, concerns of tumor seeding increase. By utilizing small incisions, the physician can view the pleural space with the assistance of a camera, and obtain sufficient tissue samples for analysis by a pathologist. Extent of the tumor (i.e., pleural involvement, chest wall invasion) may also determined, and recommendation as to the type of debulking procedure necessary can be made at this time.

Mediastinoscopy is sometimes used as an aid in staging extent of disease when enlarged nodes are seen using imaging techniques.

Laproscopy is used in mesothelioma patients in cases where imaging techniques suggest possible invasion of the tumor through the diaphragm. This information can be important in evaluating a patient for potential pleurectomy or extrapleural pneumonectomy.

Palliative Procedures

Palliative surgical procedures are those which treat a symptom of mesothelioma, without aggressively treating the disease itself.

Chest Tube Drainage and Pleurodesis is considered the most common of palliative treatments. Fluid build-up, or pleural effusion, is most often the first symptom which will prompt mesothelioma patients to seek medical attention. Once this effusion has occurred, it is many times persistent, returning rapidly after initial thoracentesis (draining of the fluid). In order to eliminate this problem, the pleural space must be closed. This is accomplished by use of a talc slurry or other sclerosing agent which produces an adhesion.

Thoracoscopy and Pleurodesis is done in conjunction with VATS using a powdered form of talc versus talc slurry. Both this and chest tube drainage and pleurodesis will be only effective if there is no tumor encasing the lung which restricts its expansion.

Pleuroperitoneal Shunt plays a limited role in palliation for several reasons. It involves placement of a catheter run under the skin from the pleural to the peritoneal cavity. Obstruction of the catheter and possible seeding of the tumor into the abdominal cavity may be concerns.

Pleurectomy, used as a palliative procedure, may be performed where more extensive surgery is not an option. In these cases, it is understood that all visible or gross tumor will not be removed. It is considered the most effective means of controlling pleural effusion in cases where the lung's expansion is restricted by disease.

Potentially Curative Procedures

These procedures are performed with "curative intent". Their goal is removal of all gross disease, with the knowledge that microscopic disease will most likely remain. Adjuvant therapy (another form of treatment in addition to the primary therapy) is typically aimed at eliminating residual disease.

For Pleural Mesothelioma:

* Pleurectomy/Decortication is usually performed on patients with early stage disease (Stage I and selected Stage II), and attempts to remove all gross tumor. If it is found that all tumor can not be removed without removing the lung, this may be done at the same time and is called pneumonectomy.

* Extrapleural Pneumonectomy is considerably more radical than other surgical approaches, and should be carried out by surgeons with great expertise in evaluating patients and performing the procedure itself. Because in the past surgery alone has failed to effect a cure, or even to help prolong life for any extended period of time, it is currently being combined with traditional chemotherapy and/or radiation, or other new approaches such as gene therapy, immunotherapy or photodynamic therapy.

For Peritoneal Mesothelioma:

* Cytoreductive Surgery is aimed at removing all or nearly all of the gross or visible tumor in the peritoneal cavity. In order to treat any remaining cancer cells, Intra-Peritoneal Hyperthermic (heated) Chemotherapy (IPHC) is then delivered to the abdominal cavity. The type of chemotherapy drug used may vary according to the physician’s preference. Click here for more on treatment of peritoneal mesothelioma.