After a diagnosis of malignant mesothelioma, your health care provider may recommend one or more surgical procedures in order to take a biopsy or to remove cancerous tissue. There are many different types of surgical procedures that ultimately may be conducted when a patient has pleural mesothelioma or another type of malignant mesothelioma. These surgical procedures or options often have technical terms that can be difficult to understand and distinguish from one another. Ultimately you should ask as many questions as possible when you are meeting with your primary care provider or a surgeon who will be conducting a procedure to ensure that you have all of the information you need.
To be clear, some surgical procedures related to malignant mesothelioma are exploratory, meaning that they will be used to determine a patient’s condition and the extent to which the malignant mesothelioma may have spread. Other surgical procedures, typically following exploratory procedures, are often designed to remove as much of the malignant tissue as possible, although a full cure from malignant mesothelioma is not usually likely even with aggressive treatment. The types of surgical procedures recommended to you will depend upon your physical condition, the symptoms you are presenting with at the doctor’s office, your medical record, your health history, and the type of mesothelioma that your healthcare provider suspects.
What is Exploratory Surgery?
In the early stages of your diagnosis when you are first presenting with symptoms, your health care provider might recommend a type of exploratory surgery in order to determine whether you have a form of malignant mesothelioma and the extent to which the disease may have spread. What is exploratory surgery? According to the National Cancer Institute, exploratory surgery is quite simply “surgery to look inside the body to help make a diagnosis.”
Thoracoscopy and Exploratory Procedures for Pleural Mesothelioma
When a patient has symptoms of pleural mesothelioma, like pleural effusion, chest pain, or shortness of breath, a health care provider might want to perform a thoracoscopy. This is a specific type of exploratory procedure that can allow a doctor to look inside the space around a person’s chest on the outside of their lungs. According to the American Cancer Society, a thoracoscopy is an exploratory surgical procedure that is conducted with a device called a thoracoscope. This is “a thin, flexible tube with a light and a small video on the end.” As the American Cancer Society explains, the thoracoscope “is put in through a small cut made near the lower end of the shoulder blade between the ribs.” Typically, anywhere from one to three smaller incisions are made in the patient in order to conduct the procedure. An incision is made for the thoracoscope, and one or two additional small incisions may be made so that the doctor can use instruments designed to retract or to take a biopsy. To be sure, the purpose of a thoracoscopy is both to give a doctor a window into a person’s chest space around their lungs, and to take biopsies of any areas that can allow the doctor to test for malignant mesothelioma.
In some patients, malignant mesothelioma will have resulted in fluid building up in the chest space around the lungs. For these patients, a thoracoscopy will first require the doctor to insert a tube into the patient’s chest in order to drain the fluid. This practice is also used for some patients who are likely ineligible for a more invasive surgical procedure in order to drain fluid and to place talc in order to prevent fluid from building up so significantly. However, doctors will usually only use talc in patients with advanced malignant mesothelioma or in patients who are otherwise poor candidates for additional surgery since instilling talc can make subsequent surgery more difficult.
A thoracoscopy is often done as a VATS procedure, according to the American Cancer Society, which is an acronym for “video-assisted thoracic surgery.” It is usually an outpatient procedure that can be completed with local anesthesia and a sedative. In some circumstances, however, it may be necessary to have an inpatient procedure conducted, in which case you will require general anesthesia and an overnight stay at the hospital.
A doctor might recommend a thoracoscopy after you present with specific symptoms, or when an imaging test like an x-ray of your chest or a CT scan shows an area that could signal an abnormality. A doctor will then focus on taking a biopsy of the abnormal area that appeared on the scan. In addition, a thoracoscopy may be used to remove small lung cancer tumors through either a wedge resection or a lobectomy (i.e., removing the love of the lung). Sometimes a thoracoscopy can also be used to remove small cancers of the esophagus or thymus gland.
Exploratory Laparotomy or Laparoscopy with Peritoneal Mesothelioma Symptoms
When a patient presents with symptoms of peritoneal mesothelioma, such as abdominal swelling or fluid buildup, a doctor might order an exploratory laparotomy. Peritoneal mesothelioma can also be known as abdominal mesothelioma, and it may be necessary to conduct an exploratory procedure in order to identify cancerous tissue in the abdomen or in a layer of the abdominal membrane.
Any kind of abdominal exploration is typically more invasive than a thoracoscopy, even though a laparotomy can still be described as an exploratory procedure. A laparotomy opens a patient’s abdomen and allows a doctor to look at various structures inside the abdomen, including the appendix, bladder, gallbladder, intestines, kidneys, ureters, liver, pancreas, spleen, stomach, uterus, fallopian tubes, and ovaries. When an exploratory laparotomy is done, the patient must be placed under general anesthesia. During the laparotomy, a doctor might take one or more biopsies of areas of concern or of areas that appeared to show abnormalities on imaging tests such as x-rays or CT scans. According to Mount Sinai, during a laparotomy, the doctor “makes a cut into the abdomen and examines the abdominal organs.” The size of the surgical cut, as well as its specific location on the patient’s body, will depend upon where the doctor suspects areas of abnormalities and what part of the abdomen the doctor needs to see. Once the surgical cut is made, the doctor will then place a tiny camera inside the abdomen. In some cases, a less invasive laparoscopy may be possible.
Surgical Procedures Following a Mesothelioma Diagnosis
When a person has been diagnosed with pleural mesothelioma or peritoneal mesothelioma, surgery may be recommended in order to remove cancerous tissue and extend the patient’s life. Some of these surgical procedures are more complicated and contentious than others, and it will be extremely important to work with your health care provider to ensure that you are a good candidate for surgery. Before performing surgery, doctors often want to consider the patient’s performance status and whether the patient is likely to respond well to surgery. When a patient’s performance status is low and surgery could result in a life-threatening outcome.
With a pleural mesothelioma diagnosis, a doctor might recommend a surgical procedure known as a pleurectomy decortication (or PD, for short). This is a specific type of surgical procedure in which a surgeon removes the lining of one or both of the patient’s lungs. The lining of the lung that will be removed will include the visceral and parietal pleura. Another common type of surgical procedure used in patients with pleural mesothelioma is called extrapleural pneumonectomy (EPP). This type of procedure involves the removal of a patient’s entire lung and pleural surfaces and, in some cases, portions of the patient’s diaphragm and pericardial sac.
According to a study published in Translational Lung Cancer Research, both EPP and PD surgical procedures are understood to be “radical operations” that may be used to treat or partially treat malignant pleural mesothelioma, but both procedures “remain controversial among thoracic surgeons.” The study emphasizes that “there is a lack of randomized evidence to support a survival benefit when major surgical resection is included in a “multi-modality treatment regimen.” Both pleurectomy decortication and extrapleural pneumonectomy have “high mortality and morbidity rates” when used in patients with malignant pleural mesothelioma, and as such, it is critical to weigh the benefits against the risks. When these surgical procedures are performed, they must be performed by a thoracic surgeon with extensive experience handling these specific types of surgeries.
With peritoneal mesothelioma, a patient may have a surgical procedure that is known as a debulking procedure. This is a surgery that is designed to remove as much of the cancerous tissue as possible—usually the cancerous tissue that is visible to the surgeon conducting the procedure. Following a debulking procedure, the patient typically receives heated and infused chemotherapy in the abdominal space. While debulking procedures are not controversial in the same way as PD or EPP procedures, they must still be done by doctors with extensive peritoneal mesothelioma expertise. In some patients, a debulking procedure might also require removing parts of a patient’s other organs or part of the patient’s bowel. Such procedures must be done by a surgeon with specific expertise in such procedures.