Surgical Procedures: Surgery and Staging for Malignant Mesothelioma

The mesothelium is a layer of tissue that surrounds and protects many organs on the inside of your body. It has a slippery layer that helps your organs move. When there are cancer cells in the mesothelium, this is called malignant mesothelioma. This cancer tends to be aggressive. Malignant mesothelioma commonly forms in the lining of the:

• Chest (pleura).
• Belly (peritoneum).

Malignant mesothelioma is rare in these areas but has been found in the lining of the:

• Testicles (tunica vaginalis).
• Heart (pericardium).

Malignant mesotheliomas are classified as:

• Epithelioid, which is the most common.
• Sarcomatoid.
• Mixed or biphasic (epithelioid and sarcomatoid).

What is staging and how is it done?

Staging is a way to find out if and how far the cancer has spread in your body. Your provider will have you get a few tests to figure out the stage of your cancer. These tests may include:

Physical Exam: This is a general exam to look at your body and to talk about past health issues. You may need a pulmonary function test to test your lung function.

Radiologic Imaging: Imaging such as a chest X-ray, CAT scan (CT scan), positron emission tomography scan (PET scan), magnetic resonance imaging (MRI) and/or echocardiogram may be used to look at the extent of your cancer.

Laboratory Studies: Your provider may have you get some blood tests. Two of these blood tests will check your levels of a protein called “osteopontin” and to see if there are “soluble mesothelin-related peptides” (SMRP’s) in your blood.

Procedures: There are a few procedures that may be used to biopsy tissue or fluid (test for cancer cells). These may include:

• Open procedures are those that are done using a large incision (cut) to look inside the body and remove tissue or fluid.
  • Thoracotomy: An incision is made in the chest. The surgeon looks in the chest cavity (space) and takes tissue for biopsies.
  • Laparotomy: An incision is made into the abdomen (belly). The surgeon looks in the abdominal cavity (belly space) and takes tissue for biopsies.
• Laparoscopic procedures use many small incisions and a small, thin tube with a lighted camera on it. The camera is inserted through the incisions and small surgical tools are used to remove tissue or fluid.
  • Thoracoscopy: A small incision is made between two ribs so that tissue, fluid, and/or lymph nodes can be removed. This may also be called a video-assisted thoracoscopic surgery or VATS.
  • Peritoneoscopy: A small cut is made in the belly so that tissue, fluid, and/or lymph nodes can be removed.
• Fine Needle Aspiration (FNA): Fluid or tissue is removed with a thin needle. It is often used to remove samples from the chest or abdomen.
• Endobronchial ultrasound needle biopsy: A bronchoscope (thin lighted camera) is used to look at the lymph nodes near the throat and the windpipe. Biopsy samples are taken with a thin needle guided by an ultrasound. 

Malignant mesothelioma can spread to other parts of the body through the tissue, lymph, and blood systems. Staging tells you how extensive the cancer is, how far it has spread, and what treatment course will be recommended. Malignant mesothelioma is described in stages I through IV. For more information, see Mesothelioma: Staging and Treatment.

Often times, it may be recommended that those with malignant mesothelioma have surgery.

Surgical Procedures for Mesothelioma

There are some common surgical procedures used to treat malignant mesothelioma. Which surgery you have depends on the stage and location of cancer, and your situation, including:

• Chest Malignant Mesothelioma
  • Wide local excision: The diseased lung and some surrounding healthy tissue is removed.
  • Pleurectomy and decortication: The covering of the lungs and chest are removed, as well as a part of the lung surface. Sometimes, the whole diaphragm and pericardium may also need to be removed. This is called a radical or extended pleurectomy and decortication.
  • Extrapleural pneumonectomy: The entire lung is removed. Also, parts of the diaphragm, chest lining, and heart sac lining and lymph nodes are also removed. After this, you may need to have diaphragm and heart sac reconstruction.
  • Pleurodesis: Lung fluid is drained, and chemicals or drugs are given to help cause scarring between the layers of the pleura. This scarring helps to stop the lung fluid from coming back.
• Abdominal (belly) Malignant Mesothelioma
  • Omentectomy: At times, the fatty tissue covering the abdominal (belly) organs (called the omentum) needs to be removed due to cancer.
• Pericardial Malignant Mesothelioma
  • When malignant mesothelioma affects the heart, parts of the sac surrounding the heart (pericardium) may need to be removed.
• Tunica Vaginalis Malignant Mesothelioma
  • When malignant mesothelioma affects the testicles, often the affected testicle is removed. At times, peritoneal (abdominal/belly) surgery may also be needed.

For many of these surgical procedures, the goal is to debulk the cancer. This means removing as much of the disease as possible.

What are the risks of malignant mesothelioma surgery?

As with any surgery, there are risks and possible side effects. These can be:

• Bleeding.
• Blood clots.
• Wound infections.
• Heart arrhythmias (change to the normal heart rhythm).
• Pneumonia (lung infection).
• Chest fluid buildup.
• Lung function problems.
• Pain.

It is important to speak with your care team about the risks of your surgery based on the type that was done.

What is recovery like?

Recovery from malignant mesothelioma surgery will depend on the procedure you have had. At times, a hospital stay may be needed.

You will be told how to care for your surgical incisions and will be given any other instructions before leaving the hospital.

Your medical team will teach you about the medications you will be taking, such as those for pain, blood clot, infection, constipation prevention and/or other conditions.

Your provider will talk to you about any activities you should avoid. Your activity will likely be limited for at least 1-2 months.

How can I care for myself?

You may need a family member or friend to help you with your daily tasks until you are feeling better. It may take some time before your team tells you that it is ok to go back to your normal activity.

Be sure to take your prescribed medications as directed to prevent pain, infection and/or constipation. Call your team with any new or worsening symptoms.

There are ways to manage constipation after your surgery. You can change your diet, drink more fluids, and take over-the-counter medications. Talk with your care team before taking any medications for constipation.

Taking deep breaths and resting can help manage pain, keep your lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to do deep breathing and relaxation exercises a few times a day in the first week, or when you notice you are extra tense.

• Example of a relaxation exercise: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.

This article contains general information. Please be sure to talk to your care team about your specific plan and recovery.