Following a malignant mesothelioma diagnosis, surgery could be recommended for you. Depending upon your specific circumstances, a doctor might recommend a type of exploratory surgery to determine whether you have malignant mesothelioma or where the cancer is specifically located. The most common type of malignant mesothelioma, pleural mesothelioma, often involves an exploratory procedure known as a thoracoscopy. With this procedure, the doctor will make small surgical incisions, typically under a local anesthetic, in order to insert a thoracoscope into your chest space to identify signs of mesothelioma or take biopsies. Other exploratory procedures can be done with signs and symptoms of peritoneal mesothelioma, which is significantly less common than pleural mesothelioma.
Beyond exploratory surgeries, extensive and invasive surgeries can be conducted to remove some or all of the mesothelioma cells in your body. Some of those surgical procedures can be controversial, such as a pleurectomy decortication (PD) or an extrapleural pneumonectomy (EPP) for pleural mesothelioma, or a debulking procedure for peritoneal mesothelioma. When these invasive surgical procedures are performed effectively, often in conjunction with chemotherapy, they can help a person with mesothelioma to live longer. However, not all patients are eligible for surgery, and doctors do not always recommend surgical procedures.
What determines whether or not you are able to have surgery when you have malignant mesothelioma? Your doctor (or team of healthcare providers, in most cases) will need to determine whether you are healthy enough to have surgery and whether the risks of the surgical procedure are likely to be outweighed by the potential benefits. For most patients, a series of tests will be conducted, and your health care providers will consider your performance status to decide whether surgery makes sense for you. Before any surgical procedure, it will be important to consider the advantages and limitations, including how the surgical procedure could ultimately affect your well-being in the short-term and long-term.
Complete Medical Assessment
Before any surgical procedure is planned, whether it is an exploratory surgery or a surgical procedure designed to treat malignant mesothelioma or to improve your likelihood of additional time, you will have a complete medical assessment. The medical assessment will determine whether you are currently healthy enough to undergo a surgical procedure, including whether or not you are currently healthy enough to handle local or a general anesthesia, and whether your body will be able to recover following the surgery.
In your medical assessment, you should expect that the surgeon performing your procedure will want to know about any potential health issues, including heart problems, lung issues, kidney problems, or liver issues. Medical conditions affecting any of these organs could reduce the likelihood that a surgeon will want to operate on you, or that you will be recommended for a surgical procedure. This medical assessment will usually be conducted by an oncologist who has experience identifying particular health issues in cancer patients that could result in more harm than good during an exploratory surgical procedure or in a surgery designed to remove cancerous tumors or tissue. You may have a medical assessment conducted by multiple members of your medical team prior to possible surgery. If you are not an ideal candidate for surgery based on your current health, your doctor will wait to perform surgery until you become healthier, or you will not have a surgical procedure conducted at all.
Medical Tests Conducted Prior to Surgery Determination
Part of your medical assessment may include a series of tests to determine your health and your ability to have surgery. Examples of those types of tests may include but are not limited to:
- Pulmonary function tests: These types of tests, commonly referred to as PFTs, are “noninvasive tests that show how well the lungs are working,” according to Johns Hopkins Medicine. In PFTs, a doctor or a team of your health care providers will “measure lung volume, capacity, rates of flow, and gas exchange.” There are two separate methods for conducting a pulmonary function test. Sometimes both methods will be used in conjunction with one another, and sometimes only one of the types of tests will be used. The first type of PFT is known as spirometry. With spirometry, “a spirometer device with a mouthpiece is hooked up to a small electronic machine.” The other type of method is known as plethysmography, in which “you sit or stand inside an air-tight box that looks like a short, square telephone booth to do the tests.” With PFTs, doctors will be measuring your tidal volume (the amount of air you inhale or exhale when you are breathing normally), minute volume (the amount of air you exhale per minute), vital capacity (the amount of air you can exhale after inhaling fully), functional residual capacity (air left in your lungs after you have exhaled normally), residual volume (air in the lungs after you have exhaled as much as possible), total lung capacity (volume of the lungs when they are fully filled with air), forced vital capacity (amount of air you can exhale “forcefully and quickly after inhaling as much as you can”), forced expiratory volume (air exhaled during the forced vital capacity test), forced expiratory flow (average rate of airflow during the forced vital capacity test) and peak expiratory flow rate (fastest rate at which you are able to force air out of your lungs).
- Cardiac ultrasound: A cardiac ultrasound, according to the National Institutes of Health (NIH), is “a noninvasive diagnostic modality that can provide detailed hemodynamic information in a short period of time at a patient’s bedside.” In other words, this is a test that is used to determine how healthy your heart is and whether it is functioning properly. There are two different methods for conducting a cardiac ultrasound, including a subxiphoid process and a parasternal long axis process.
- Electrocardiogram (EKG): An electrocardiogram is another type of test that is used to determine how healthy a person’s heart is and whether that person may be able to safely have a surgical procedure. According to the Mayo Clinic, an electrocardiogram “records the electrical signals in the heart,” and it is a “common and painless test used to quickly detect heart problems and monitor the heart’s health.” It can be known as an ECG or an EKG. There are two different methods for conducting an electrocardiogram: through a holter monitor, or through an implantable loop recorder. A holter monitor is a wearable device that the patient usually wears for approximately 24 to 48 hours. There are also wearable monitors that are known colloquially as event monitors, or implantable loop recorders, that can be worn for up to a month to assess a person’s heart condition. With an event monitor, the patient typically pushes a button if any symptoms are present, but the device itself can also record any irregularities. These wearable devices are placed just under a patient’s skin on their chest.
- Preoperative blood tests: Many different blood issues may be assessed through a blood test prior to determining whether you are fit to have surgery. According to Johns Hopkins Medicine, blood tests prior to a surgical procedure, or preoperative blood tests, will typically be used to assess a patient’s white blood count (to identify the presence of infections or medicines), glucose (to check a patient’s blood sugar levels), potassium in the blood (which, along with sodium and electrolytes, can regulate your heart rhythms and other essential functions), a complete blood count (as known as a CBC, which checks for infections and anemia or low number of red blood cells), and coagulation studies (also known as PT/PTT, which will be used to determine your blood’s clotting abilities).
All of these tests will look for any physical abnormalities or health issues that could affect your ability to survive the surgical procedure or to heal afterward.
All of the tests and the medical assessments described above will be used in part, along with discussions with the patient, to determine the patient’s performance status. The performance status, or PS, is a streamlined way of identifying a patient’s ability to be mobile and to provide for themselves in terms of performing activities of daily living (ADL). There are two different scales that can be used to determine a patient’s performance status, and both types of scales use numbers.
The Zubrod Scale classifies a patient from 0 to 4, with 0 being the most fit for a surgical procedure and 4 being the least fit. The Karnofsky Scale classifies a patient from 100 to 10, with a patient at 100 being the healthiest and most fit for surgery and a patient at 10 being the least fit for surgery and near death.
Even when patients have a performance status that allows them to be good candidates for surgery, and health assessment and test results that make surgery a possibility, it is still important to discuss the benefits and limitations with your health care providers. Many surgeries used to treat malignant mesothelioma can be extremely invasive and aggressive. For some patients, the risks ultimately could outweigh the possible benefits.