Surgical Procedures for Diagnosis
If it can be avoided, doctors prefer not to use surgery as a diagnostic tool. It is always better to use less invasive strategies, but getting an accurate diagnosis is crucial for treatment and a clear prognosis, so sometimes diagnostic surgical procedures are necessary. A biopsy is a simple surgical strategy, which is not usually very invasive, and which can be used to determine if a tumor is malignant, and if it is, what type of cancer it is.
A biopsy involves removing samples of fluid, tissue, or both from a tumor, the fluid-filled areas of the mesothelium, or from an area where tumors are suspected but not confirmed. The simplest biopsy is a fine needle aspiration. The procedure involves inserting a thin, hollow needle, through the skin and into the area from which the sample will be collected. It requires only local anesthetic and is quick.
More invasive diagnostic surgeries may be needed if it is impossible to access the tumor with a needle. A core or incisional biopsy involves making a surgical incision so that the surgeon can reach the tumor and remove a small sample of tissue. To diagnose pleural mesothelioma, a patient may need to undergo a thoracoscopy or thoracentesis.
A thoracentesis involves draining fluid from the pleura for testing. This procedure can also be used as palliative care too, as draining out the fluid makes breathing easier and less painful. A thoracoscopy is more invasive and requires an incision so that a probe can be inserted to sample the pleural tissue.
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.
A pleurodesis may be performed to prevent future buildup of fluid in the chest cavity. To do it a small tube has to be inserted into the chest through an incision, which is left in for a day or two. A shunt may also be surgically placed to move fluid from one part of the body, where it is causing discomfort, to another from which it will be better absorbed. Debulking surgery, which removes as much of the cancer as possible, can also be palliative but not every patient is a good candidate for it.
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
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.
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.
For pericardial mesothelioma, the cancer of the tissue around the heart, surgery is not common. It is very 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.
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. 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, MD
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.