Radical surgery is only appropriate for a small number of mesothelioma patients and aims to remove all, or most of, the visible tumour. There is no guarantee, however, that it removes all cancer cells as some may not have been detected or may be difficult to remove.
Two radical surgical options exist, extrapleural pneumonectomy (EPP) and radical pleurectomy and decortication (P/D).
Extrapleural Pneumonectomy (EPP)
EPP is suitable for patients suffering from pleural mesothelioma, which tests show has not led to cancer cells spreading to other areas of the body. EPP involves removing the whole lung and pleura together with the diaphragm and the side of the pericardium (the sac around the heart) in one piece. After removal of the tumour, the diaphragm and pericardium are reconstructed with artificial patches.
Radical Pleurectomy and Decortication (P/D)
Where the lung is surrounded by a tumour and, even after pleural effusion the lung cannot expand, then the surface of the lung may be skimmed (decortication) to help the lung to expand. The lung is left in place during P/D but the thickened pleural membrane covering it is skimmed off and the pleura stripped off the chest wall. The pericardium and diaphragm may be removed, depending on the extent of the tumour.
The surgery usually leads to better lung function for the patient but, because it is not as radical as EPP, it is more likely that tissue containing cancer cells remain and there could be a greater recurrence of the disease.
Decortication often involves opening the chest with a large cut made around the back, between the ribs, this is called a thoracotomy although in some cases it can be performed by keyhole surgery. More elderly patients can have a “pleuro- peritoneal shunt” which is a drain with a valve which empties the pleural fluid into the abdominal cavity where it is absorbed.
Palliative Surgery
The type of operation performed depends on the effects that draining fluid around, for example, the lung (pleural effusion) has had on the patient and the health of the patient. Sometimes if the pleural effusion has been successful in helping the lung to function better, sterile talc may be placed round the lung, to seal the space between the pleural linings (pleurodesis) or a removal of the tumour (pleurectomy) may take place.
Pleurodesis makes the two layers of the pleural membrane stick together which closes the space between them and stops the formation of further effusions.
Both these procedures can be performed by keyhole surgery Video Assisted Thoracoscopic Surgery (VATS).