Surgery for pleural mesothelioma

Pleural mesothelioma starts in the layers of tissue that cover the lung (pleura).

Surgery is not a common treatment for mesothelioma. Some people might have an operation to control and relieve symptoms. The surgery might also help them to live longer. 

To have surgery you have to be fairly fit and well so that you can recover without too many problems.

Researchers are looking at the role of surgery for people with pleural mesothelioma. Depending on your situation, your doctor may discuss an operation with you. They can explain the risks and benefits of surgery and what clinical trials have shown so far.

Talk to your healthcare team if you are unsure whether surgery is an option for you. You could ask for the opinion of a specialist mesothelioma surgeon. Your consultant can refer you to a mesothelioma surgeon if there isn’t one at your local hospital.

Types of surgery

Surgery can be used to try to completely remove the mesothelioma. You might have an operation to remove:

• part of the pleura (partial pleurectomy) or
• the whole of the pleura (pleurectomy)

Removing part of the pleura

The surgeon removes the part of the lining of the lung (pleura) that contains the mesothelioma.

This is a major operation that is sometimes carried out using keyhole surgery. The surgeon makes between 1 and 3 small wounds, each about an inch long. They take as much of the mesothelioma away as possible. They also put a substance into the space to stop fluid from building up in the future.

Instead of keyhole surgery, your surgeon might need to make a large wound in your chest.  

You need to stay in hospital for about 7 days afterwards. It takes about 4 to 6 weeks to fully recover.

Research
Surgeons don't often carry out this operation. MesoVATS was a UK trial. It compared this operation with a simpler procedure called pleurodesis. Pleurodesis is when the doctor drains off any fluid that has built up in the chest. They then put sterile talc into this space to help stick the lining of the lung to the chest wall.

The researchers followed people in both treatment groups. They looked at their quality of life and how long people lived. There was no difference between the 2 groups in terms of how long people lived. After 6 months, the quality of life for people who had a partial pleurectomy was a bit better. But the researchers did not think this difference was significant enough. So they weren't able to recommend one treatment over the other. 

If you have symptoms, such as shortness of breath, your surgeon may discuss this operation. Or they might suggest a pleurodesis.

Removing the whole pleura

The surgeon removes the whole pleura from around the lung on the affected side. They make a large wound in your chest called a thoracotomy. They remove the pleura and then replace it with a specialised medical mesh layer.  

You might have a slightly bigger operation called a pleurectomy decortication. This involves the removal of:

• any visible mesothelioma
• the hardened and thickened outer layer of the surface of the lung (decortication)
• the lung covering (pleura)

Depending on where the cancer is in the covering of the lungs, some people also have the removal of:  

• part or all of the lining of the heart (the pericardium)
• the sheet of muscle just under the rib cage (the diaphragm)

This operation is called an extended pleurectomy decortication. You may have this operation with chemotherapy for early stage mesothelioma. 

All of these pleurectomy operations leave the lungs in place. So they are called lung sparing operations. They take place in specialist hospitals in the UK. You stay in hospital for 10 to 15 days afterwards. It takes about 6 to 8 weeks to fully recover.

MARS 2 trial

The role of a pleurectomy decortication is being looked at in a large trial called MARS 2. In one group, people have chemotherapy alone. People in the other group have chemotherapy and surgery. The researchers want to find out if people who have surgery live longer than those who don’t. They are also looking at the quality of life in each group. The trial results are expected in 2023.

Removing the lung and pleura

There is another type of operation that removes the lung and muscle on the affected side, as well as the pleura. This is called an extrapleural pneumonectomy. A trial called MARS1 looked at this operation.

Surgeons in the UK now have the results of the MARS1 trial. They have decided that this operation did not benefit their patients. So they rarely use it in the UK. We mention it here because you might read about it on some other websites. 

Surgery for advanced mesothelioma

This surgery aims to remove as much tumour as possible to relieve symptoms. It is called palliative surgery or debulking. It can help to reduce breathlessness.

Clinical trials

Your doctor might ask if you’d like to take part in a clinical trial. Doctors and researchers do trials to make existing treatments better and develop new treatments.