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Surgery



Surgery along with chemotherapy and radiation therapy is one of the traditional treatment method for mesothelioma.

There are two kinds of malignant mesothelioma surgery having different aims: an aggressive surgery is aimed at long-term control of the symptoms and palliative procedures are carried out in order to relieve them.

Aggressive Surgery. Extrapleural pneumonectomy, involving the removal of pleura, the lung, the diaphragm and the pericardium, is the most wide-spread type of aggressive surgery. This aggressive and difficult procedure is aimed at removing the tumor cells in maximum possible volumes. This procedure is not carried out by all hospitals because of its very specialized nature and high risk concerning death within the period of 30 days after the surgery is done. In order to find out whether the patient is able to tolerate this surgery, he or she is evaluated carefully, nevertheless, extrapleural pneumonectomy is mostly appropriate for younger patients because of their health and earlier stages of cancer.

Palliative Surgery. The symptoms of advanced malignant mesothelioma can be relieved and controlled via this surgical method. Patients often suffer the reduction of the lung function, caused by various reasons; the most common is collection of the fluid (pleural effusion) and the tumor compressing the lung with its mass. These processes can lead to breathlessness and chest pains.

Surgery is generally not the cure, but it is a good means to prolong the patient's life considerably. A careful evaluation of the patient's entire health is required while deciding whether to apply surgery to malignant mesothelioma. The aim of this testing is to ensure that the cancer didn't produce metastases and advanced to other organs, as well as to find out the general health of the lung and heart functions of the patient.

Three procedures are used in the surgical management of MPM:

  • thoracoscopy with pleurodesis
  • pleurectomy/decortication (P/D)
  • extrapleural pneumonectomy (EPP)

Thoracoscopy

This is used mostly for obtaining a sample of tissue for diagnosis, but it is also useful in palliative treatment of recurrent or symptomatic pleural effusions for pleurodesis. There is no considerable difference in the effect of usage such sclerosing agents as bleomycin, tetracycline, and talc. The cheapest agent is talc and, moreover, it can be fed through a chest tube as slurry or through thoracoscope.

Pleurectomy/decortication (P/D)

During this procedure the visceral, parietal, and pericardial pleura are removed from the apex of the lung to the diaphragm. At early stages of the disease only complete resection is appropriate, though the majority of these patients suffer local recurrence. The retained lung limits the doses of postoperative radiation compared to EPP. Pleurectomy/decertification may treat the disease at its very early stage T1a. It goes along with high local recurrence rate and survival not more than 5 years.

There is no clear data concerning the fact whether adjuvant radiotherapy or chemotherapy, neoadjuvant therapy, radiation, intrapleural chemotherapy or brachytherapy and others can improve survival. The most common usage of pleurectomy/decertification is for palliation symptoms and treating in case planned extrapleural pneumonectomy is not appropriate. An effective in extending survival and safe treatment was found during recent research of dyperthermic perfusion utilizing intrapleural cisplatin at a dose up to 225 mg/m2 and i.v. thiosulfate.

Extrapleural pneumonectomy (EPP)

It is the most aggressive treatment. During this procedure the en bloc resection of the visceral and parietal pleura, lung, pericardium, and ipsilateral diaphragm is carried out. The surgeon and institution performing the operation critically select patients for EPP.

Extrapleural pneumonectomy for stage I and II induces long term survival in about 20% of patients. Careful selection of patients utilizes premorbid exercise capacity, absence of bronchitis or astma (Butchart 1999). It is a surgery riddled with mortality, particularly if done in the right hemithorax and out of skilled centers. Extrapleural pneumonectomy is often done as part of multimodality therapy, including chemotherapy intrapleural hyperthermic and cisplatin based, radiation to the operated hemithorax, and systemic adjuvant chemotherapy.

Thoracentesis is commonly performed to treat effusion in pleural mesothelioma. This surgery involves inserting a needle into the chest to drain the excess fluid, relieving breathlessness and chest pain. Talc may be introduced into the pleura to limit recurrence of the effusion. Pleurectomy is the surgical removal of the pleura. This procedure is performed to reduce pain caused by the tumor mass, or to prevent the recurrence of pleural effusion. For peritoneal mesothelioma, surgery generally is aimed at relieving symptoms, such as recurrent ascites or bowel obstruction. As with pleural mesothelioma, complete surgical removal of the entire tumor is unlikely.

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