The process of mesothelioma diagnosis seems like an endless series of tests, some of which require anesthesia or even hospitalization. By the time you even begin treatment for mesothelioma, you may feel like, in the past few months, you have had more doctors’ appointments, blood tests, and X-rays, than at any other time in your life. There are still more tests before the doctors can decide which treatment is best for you. Unfortunately, none of the treatments for mesothelioma are completely painless or will quickly restore you to the same state of health that you enjoyed before you began experiencing symptoms of mesothelioma. The saying “the cure is worse than the disease” could apply to some cancer treatments, because of the side effects and risks involved. Patients, with the help of their doctors, choose to consent to treatments based on which treatment or treatments will be best for prolonging life expectancy, or both.
Pleurectomy Decortication and Extrapleural Pneumonectomy: The Two Most Common Surgeries for Pleural Mesothelioma
Pleural mesothelioma is a type of cancer that forms on the pleurae and, if untreated, can spread to other parts of the body. It can start on the parietal pleura, which lines the inside of the chest wall, or the visceral pleura which covers the outside of both lungs. In most cases, mesothelioma has spread to both pleurae by the time a diagnosis is made. The purpose of treating mesothelioma with surgery is to remove macroscopic disease, that is, to remove all portions of the cancerous tumor that are large enough to be visible to the naked eye; this is the goal of surgery for most other types of cancer, too. Therefore, doctors often recommend chemotherapy or radiation therapy to eradicate microscopic cancer cells in addition to surgical removal of large tumors.
The most common surgery for treatment of pleural mesothelioma is called pleurectomy decortication (PD). This surgery involves removal of both pleurae on the affected side of the chest. Even in the best-case scenario, PD leaves patients with reduced lung function, and they require supplemental oxygen at least for a while after surgery.
If the cancer has spread far enough that PD is not an option, then doctors resort to the other surgery for treatment of pleural mesothelioma, namely extrapleural pneumonectomy (EPP). In this procedure, doctors remove an entire lung, as well as its pleurae and part of the pericardium and diaphragm. During the surgery, doctors must reconstruct the removed part of the diaphragm and pericardium so that the heart and the remaining lung can continue to function after the surgery.
Both surgeries require the insertion of a chest to tube to drain excess fluid; you may need to keep the drainage tube in for up to ten days after the surgery. After both surgeries, you will need to practice taking deep breaths, to ensure that you have the greatest possible breathing capacity with what remains of your lungs. This can be accomplished through a combination of medication and pulmonary physical therapy.
What Determines Which Mesothelioma Surgery, If Any, You Can Get?
As stressful as it is to prepare yourself for breathing with only one lung for the rest of your life, it is even more stressful to find out that you might not even be able to have the surgery because you have too many health risks. For example, doctors will need to make sure that your heart will be able to tolerate the surgery and that your lung function is sufficient that the surgery will make it easier to breathe instead of more difficult.
In general, it is easier to recover from PD than it is from EPP. It is a relief to find out that your thoracic surgeon thinks that you are a candidate for PD and that you do not need to have an entire lung removed. Your medical team will choose a strategy for surgery after a long series of diagnostic imaging studies and other tests, and they will only perform the surgery if you consent to it. Since the median survival time after EPP is only about one year, some patients decide that the increased life expectancy is not worth having to cope with having only one lung, and they choose less aggressive treatments instead.
Even after all those tests, sometimes doctors cannot tell exactly where your macroscopic cancer is, and where it is not, until you are already on the operating table and the doctors are seeing your lungs and chest wall up close. They may need to decide, in the moment, to do an EPP, even though the diagnostic images previously made it look like you were a good candidate for PD. Your doctor will discuss all of this with you in detail before you consent to surgery.
In some instances, previous treatment for mesothelioma could make it difficult or impossible for your doctors to perform surgery. This is why it is important to see a mesothelioma expert, preferably one who has published their research in peer-reviewed journals, before you begin treatment, even if it means a slight delay in initiating your treatment, and even if it means you must travel out of town to visit the mesothelioma specialist. It is important to include doctors who have up-to-date knowledge about the constantly evolving mesothelioma treatments that play a role in the decisions about your treatment. For example, draining fluid from patients’ chest cavities to facilitate breathing is a common part of mesothelioma treatment and is quite effective at relieving symptoms, but some doctors who do not specialize in mesothelioma will insert talc to prevent the fluid from coming back. This is fine when the reason for the fluid buildup is something other than mesothelioma, but it poses problems regarding mesothelioma surgery. The talc causes the lung to adhere to the chest wall, which creates obstacles to successful PD or EPP.
The prognosis for cancer is always better the earlier it is diagnosed, and if your mesothelioma is at an early stage at the time of diagnosis, it is still important to visit a mesothelioma specialist. Expert opinions vary about when it is appropriate to perform surgery for early-stage mesothelioma, and a knowledgeable mesothelioma doctor can give you the best advice.
Why Do Doctors Do Tests Before Surgery?
After your doctors have decided which surgery they plan to perform, they must still do more tests to see if your heart is strong enough for surgery and to test your lung function to see what kind of treatment you will need to regain the best possible lung function after surgery. Therefore, the first test they perform is called an echocardiogram. An echocardiogram is an ultrasound imaging test of the heart. It shows you the heart’s structure and function in real time and in much more detail than an X-ray. It enables doctors to see moving images of your heart instead of just still pictures. You might undergo one echocardiogram while at rest, followed by a stress test, while doctors take echocardiogram images of your heart while you exercise, such as by walking on a treadmill. If your cardiovascular health is not good enough to withstand the stress of surgery, then your doctor might tell you that mesothelioma surgery is not an option.
The other important test you will need before you can undergo mesothelioma surgery is a quantitative lung perfusion scan. This is a radioactive nuclear can that enables doctors to see how much air passes through each part of each lung. It therefore helps them figure out what your lung function will be like after they remove one lung or parts of it. Based on the results of the quantitative lung perfusion scan will also give doctors valuable information to help them develop a recovery plan for you after surgery and estimate how long after the surgery you will continue to need supplemental oxygen. In some cases, the results of the quantitative lung perfusion scan could even persuade doctors that removing one of your lungs would shorten your life expectancy instead of prolonging it or make your quality of life worse instead of better.
Surgery Is Only One Aspect of Mesothelioma Treatment
Another reason that doctors perform so many tests before surgery is that you will probably also have to undergo other treatments in addition to the surgery. Even if doctors are able to remove the entire tumor, so that no cancerous tissue is visible, they cannot be sure that no remaining cancer cells are present. You will need more blood tests, imaging studies, and biopsies to see whether there are any other signs of cancer. Depending on the results, you may need chemotherapy, radiation, or both. Sometimes oncologists perform chemotherapy or radiation after surgery as a precaution, to increase their chances of destroying all the cancer cells in your body, or as many of them as possible. Like surgery, chemotherapy and radiation therapy are physically and emotionally stressful, and before beginning any of these treatments, doctors will perform more tests to help them predict how well you will tolerate the treatment.