Mesothelioma is a cancer that is most often linked to asbestos exposure. It can involve the lining of the lung (pleura) or of the belly (abdomen but are also found on the lining of the abdomen, heart or testicles. Pleural and abdominal mesotheliomas are the most common. Treating mesothelioma surgically remains difficult because it spreads along surfaces of these linings.
To perform surgery, accurate tumor staging is imperative since many patients in later stages of the disease are not candidates for some of the more radical approaches.
There are generally two surgical categories for the treatment and management of mesothelioma, cytoreductive (which aims to cure) and palliative (which aims to relieve symptoms).
Cytoreductive surgeries are radical and invasive techniques that focus on removing all of the cancer. These types of surgeries are only recommended for patients who are in good health and diagnosed with stage I or stage II mesothelioma. Some forward looking surgeons use the Sugarbaker technique which removes all cancer as well as the lining itself.
Extrapleural pneumonectomy (EPP) has been a standard treatment for pleural mesothelioma for many years. EPP involves the removal of the entire lung, diaphragm and pericardium. The diaphragm and pericardium are reconstructed synthetically after removal.
In studies so far, if aggressive surgery can be performed, five-year survival rates were as high was 46 percent.
Pleurectomy/Decortication (P/D) also involves surgically removing tumors. However, the lung is left mostly intact. Improved pulmonary function results in a lower mortality rate over EPP, but P/D has a slightly higher level of tumor recurrence. Postoperative radiation therapy is also limited because of the intact lung.
Both EPP and P/D are extremely invasive and the risk of morbidity and mortality are present for both procedures. Medical controversy still surrounds which procedure is more effective. More studies have yet to compare the effectiveness of these surgeries to systemic therapy and symptom control.
Palliative surgery is a more conservative treatment. It focuses on the prevention and management of pleural effusion (fluid in the lining of the lungs) and tumor debulking to relieve chest pain and allow lung expansion. Debulking means removing the bulk of the cancer, but not to attempt to remove it all. For patients in later stages of the disease, palliative treatment offers relief from symptoms and prolonged survival.
Other procedures such as pleurodesis can relieve symptoms by surgically inserting a talc mixture to close the pleural space and remove the place where fluid can accumulate. A permanent chest drain can also be inserted to prevent the build-up of fluid.
Though surgery remains an option for the treatment of mesothelioma, many experts advocate an aggressive multimodal approach that uses chemotherapy and radiation together with surgery, in an attempt to improve on long term results.
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