Surgical Procedures for Diagnosis
The goal of a biopsy is to use the least invasive approach to gain the most information for a diagnosis. A biopsy can determine if an abnormality is cancer and what kind it may be. The type of cancer impacts the usefulness of each type of biopsy. For example, some cancers can provide doctors a complete diagnosis from very few cells. Other cancers are more complex and require larger biopsies to provide more information to complete the diagnosis. Because most mesothelioma is rare and complex, it usually requires a larger biopsy for doctors to feel confident they have a complete diagnosis.
Here are some common types of biopsies that may be discussed with you. These procedures may occur at the time of your initial diagnosis or throughout your diagnosis to gather more information.
1. Fine needle aspiration (FNA) is the simplest biopsy. The procedure involves inserting a thin, hollow needle through the skin to reach the intended biopsy region. It only requires a local anesthetic and is usually quick.
2. Core needle biopsy is very similar to a fine needle aspiration, but the size of the needle is larger, so more cells are able to be withdrawn.
3. Incisional biopsy is when a surgeon makes an incision to remove a small sample of tissue.
4. Thoracoscopy procedure involves undergoing general anesthesia and a surgeon using a camera scope to look inside the chest cavity and take a biopsy from the lung or pleura. This can also include a thoracentesis at the same time, which is removing fluid from the lung cavity.
5. Mediastinoscopy involves undergoing general anesthesia and the surgeon sampling lymph nodes in the center of your chest. This is usually after confirmation of mesothelioma and helps determine the stage of your cancer.
6. Laparoscopy procedure also involves general anesthesia and the surgeon uses a camera scope to look for abnormalities perhaps too small to be seen on imaging studies. They can take several biopsies from the abdominal cavity, including the omentum or other organs. This is often paired with peritoneal washings, where the surgeon instills a salt-water solution into the abdomen and then removes the fluid to check for cancer cells.
Although these invasive procedures do have risks, they offer more tissue and are more helpful information used for diagnosis.
One of the most common reasons to turn to surgical procedures for a patient with mesothelioma is for palliative care. This is the type of care a patient receives to improve symptoms and quality of life when there is little to no hope of a cure. Palliative care is all about relieving pain and bringing as much physical comfort and improved quality of life to a patient as is possible and reasonable. These strategies may also be used in patients with a chance of being cured, but this is less common.
Draining fluid is one of the most common palliative procedures. Fluid builds up between the two layers of the mesothelium as cancer develops, and this can cause pain and difficulty breathing around the lungs or heart and swelling and pain in the abdomen. Depending on where the fluid is removed the process may be called:
- Thoracentesis – for draining fluid from around the lungs
- Pericardiocentesis – the removal of fluid from around the heart
- Paracentesis – draining fluid from the abdominal cavity
Each of these procedures involves inserting a hollow needle between layers of tissue to draw out the fluid. The strategy is not permanent, and as fluid builds up again it will need to be repeated; additionally, in some cases, permanent indwelling catheters can be left in the lung or abdomen so patients can drain this fluid on their own at home.
A pleurodesis is a surgical procedure aimed to prevent the ability of fluid to reaccumulate by eliminating the space between the lung layers. This procedure creates inflammation of the lining so that they stick together, leaving no space for the fluid to reaccumulate. A chemical pleurodesis involves instillation of a drug using a small incision in the chest cavity using a small camera. Common drugs used over the years include talc, bleomycin, tetracycline, doxycycline, or iodopovidone. A mechanical pleurodesis manually irritates the pleura to create inflammation. There is usually a chest tube left in for a few days after the procedure. This helps remove any remaining fluid and provides additional suction for the lining to fully adhere together. The tube is then removed before going home.
Curative mesothelioma surgery is not very common. Most people are diagnosed with this type of cancer after it has already spread to other parts of the body. At this later stage it is considered impossible to cure the cancer by surgically removing tumors.
If, however, mesothelioma is diagnosed in a patient at stage I, or maybe at stage II, the cancer will not have spread very far and could be cured with aggressive surgery. In these cases the surgery has the goal of removing all of the cancer. Radiation and chemotherapy are usually used after curative surgery to eliminate any remaining cancer cells.
Surgery for Pleural Mesothelioma
The cancer of the pleura around the lungs is the most common type of mesothelioma. Most surgeries to treat it are palliative, not curative. The best chance of curing pleural mesothelioma, in patients who are eligible for it, is to perform an extrapleural pneumonectomy or EPP.
This aggressive surgical procedure involves the removal of the entire lung, along with the pleura, from the side in which the cancer is found. It is a complicated surgery and only certain patients are good candidates for it.
Less extensive and less risky is a pleurectomy, which involves the removal of all of the pleura from one lung. In a radical or extended pleurectomy, other tissues may be removed as well. A debulking surgery is used to remove as much cancerous tissues as possible, but typically does not involve removing all of the pleura.
Pleurectomy surgery, also known as pleurectomy with decortication (P/D), is typically reserved for patients in either stage one or stage two of the cancer. The goal of the surgery is to help prevent the cancer from spreading and to prevent liquid build-up in the pleura.
Patients often have multi-modal treatments with pleurectomy surgery, meaning that they may also undergo chemotherapy or radiation therapy, or both. Patients who receive multi-modal treatments reportedly have better survival rates when compared to patients who only undergo surgery.
Surgery for Other Types of Mesothelioma
Debulking is a common type of surgery for patients with peritoneal mesothelioma, the cancer that attacks the lining of the abdominal organs. As with pleural mesothelioma, this can be done to try to cure the cancer if it is in the early stages or as palliative care.
Some patients with this type of mesothelioma may also undergo an omentectomy, surgery to remove the omentum. This is a layer of fatty tissue that covers the abdominal organs. Peritoneal mesothelioma often spreads to this tissue, necessitating its removal.
Cytoreduction is also a common form of surgery for peritoneal mesothelioma. It involves removing the abdomen lining, along with any visible tumors in the surrounding area.
Cytoreduction is a possibility for all mesothelioma victims, regardless of stage. If the patient is still in early stages, physicians will treat the surgery as curative. For later stages, cytoreduction will be palliative. Surgery typically lasts around ten hours. Studies suggest that the majority of patients who undergo cytoreduction extend their livelihood to around seven years.
Patients who undergo cytoreduction may also undergo chemotherapy at the same time. A common form of chemotherapy that accompanies cytoreduction treatment is hyperthermic intraoperative chemotherapy (HIPEC), and it’s performed at the same time as surgery.
According to the U.S. National Institutes of Health, “cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) combined have been recognized as standard of care for treatment of a subset of patients with peritoneal carcinomatosis (PC).”
For pericardial mesothelioma, the cancer of the tissue around the heart, surgery can be done, although it is not common. It is tricky to try to remove cancer from the pericardium, simply because it is so close to the heart. It can be done, but it is rare. For both pericardial and peritoneal mesothelioma, removal of fluid is a more common procedure to help patients feel more comfortable.
A common form of surgery for pericardial mesothelioma is pericardiectomy, which entails removing the lining around the heart. Sometimes only part of the lining is removed but in other instances, the entire lining could be removed. The goal of pericardiectomy surgery is to lessen fluid buildup around the heart, which can help it to function as it should.
Tumor resection is another form of surgery for pericardial mesothelioma patients. Surgeons attempt to remove the cancerous tumors without removing the lining of the heart. According to the American Cancer Society, tumor removal doesn’t cure the cancer, but it helps patients live longer.
Goals of Surgery
There are several different goals of using surgery as a treatment for any type of mesothelioma, and these vary depending on the patient: to diagnose, to cure, to treat, to manage symptoms, and to slow disease progression. Surgery can also be used to improve quality of life. The type of procedure used depends on the stage of the cancer, the location of the cancer, and the overall health and prognosis of the patient.
Radical and aggressive, curative surgeries are only reserved for patients with cancer that has not spread too far and for those who are generally healthy enough to withstand the physical trauma of such a procedure. For other patients, surgeries are used more often as palliative care.
Surgery for any reason is serious and includes risks that can result in complications, ranging from mild to severe. Patients may even die while undergoing surgery, so choosing this kind of treatment should be well informed. Any of these surgeries can result in excessive bleeding, blood clots, infections, and other, more specific complications, including heart problems. Choosing a surgical procedure for mesothelioma should be made together with an experienced medical team and the patient’s closest loved ones.
Page Medically Reviewed and Edited byLuis Argote-Greene, M.D.
Luis Argote-Greene is an internationally recognized thoracic surgeon. He has trained and worked with some of the most prominently known thoracic surgeons in the United States and Mexico, including pioneering mesothelioma surgeon Dr. David Sugarbaker. He is professionally affiliated with University Hospitals (UH). His areas of interest and expertise are mesothelioma, mediastinal tumors, thoracic malignancies, lung cancer, lung transplantation, esophageal cancer, experimental surgery, and lung volume reduction. Dr. Argote-Greene has also done pioneering work with video-assisted thoracoscopic surgery (VATS), as well as robotic assisted minimally invasive surgery. He has taught the procedures to other surgeons both nationally and internationally.