Understanding Potentially Curative Surgery for Mesothelioma

If you or a loved one is facing malignant mesothelioma, you may have heard about surgical options aimed at a cure. While mesothelioma is an aggressive cancer, certain surgical approaches—combined with other therapies—offer hope for prolonged survival.

There are two primary surgeries used in an attempt to remove all visible disease:

1. Pleurectomy/Decortication (P/D) – A lung-sparing surgery that removes the pleura but preserves lung function.
2. Extrapleural Pneumonectomy (EPP) – A more radical surgery that removes the pleura, lung, diaphragm, and pericardium.

Both procedures aim to eliminate as much cancer as possible while recognizing that microscopic disease often remains. This is why adjuvant treatments—like chemotherapy, radiation, and immunotherapy—are used after surgery.

Let’s explore the details of these procedures, who qualifies for them, and how they fit into a broader treatment plan.

Surgical Candidacy: Who Can Undergo Curative Surgery?

Before performing surgery, doctors must determine if a patient is a good candidate. The decision is based on:

• Cancer Stage – Early-stage mesothelioma (Stage I-II) is more likely to be resectable.
• Tumor Location – If the tumor has spread beyond the pleura, surgery may not be effective.
• Lymph Node Involvement – N0 or N1 disease is more favorable for surgery; N2 disease may rule it out.
• Overall Health – The patient must be strong enough to handle major surgery.

A comprehensive evaluation includes:

1. Pulmonary function tests – Determines if the patient can tolerate lung removal (in cases of EPP).
2. Cardiac evaluation – Includes echocardiography to check for pericardial involvement and stress testing to ensure the heart is strong.
3. Imaging scans – CT, MRI, and PET scans assess tumor spread and determine surgical feasibility.
4. Minimally invasive procedures – Thoracoscopy, mediastinoscopy, and laparoscopy help refine staging before committing to surgery.

Key Takeaway: Not all mesothelioma patients qualify for curative surgery. Careful selection is crucial to avoid unnecessary risks.

Pleurectomy/Decortication (P/D) – A Lung-Sparing Option

What is P/D?

Pleurectomy/Decortication (P/D) is a less radical surgical approach that removes:

• The parietal and visceral pleura (the lining of the lung and chest cavity).
• Tumor nodules from the lung surface and diaphragm.
• Any involved pericardium (if needed).

Unlike extrapleural pneumonectomy (EPP), P/D preserves the lung, making it a preferred option for patients with good lung function.

Who is a Candidate for P/D?

P/D is usually performed on:

• Patients with early-stage mesothelioma (Stage I-II).
• Patients with epithelial mesothelioma, as they have better surgical outcomes.
• Patients who are not candidates for EPP due to poor lung function or other health issues.

The Procedure

1. Surgeons access the chest cavity through a thoracotomy.
2. The pleura (cancerous lining) is carefully removed from the lung.
3. Tumor tissue is dissected from the diaphragm and pericardium.
4. Surgeons ensure that all visible tumor is removed before closing the incision.

Outcomes and Benefits

Key Takeaway: P/D is ideal for patients who want a lung-sparing approach while still aiming for maximal tumor removal.

Extrapleural Pneumonectomy (EPP) – A More Radical Approach

What is EPP?

Extrapleural Pneumonectomy (EPP) is an extensive surgery designed to remove all visible mesothelioma in the affected lung and surrounding structures. This means:

• Complete removal of the pleura (parietal and visceral).
• Removal of the entire affected lung.
• Resection of the diaphragm and pericardium, replaced with synthetic patches.

EPP is a high-risk procedure, but it offers better local disease control compared to P/D.

Who is a Candidate for EPP?

EPP is typically considered for:

• Patients with Stage I-II mesothelioma without lymph node involvement.
• Patients with good lung function who can tolerate living with one lung.
• Patients undergoing multimodal therapy (surgery + chemotherapy + radiation).

The Procedure

1. A large incision is made along the side of the chest.
2. The lung, pleura, diaphragm, and pericardium are carefully removed.
3. Synthetic patches replace the diaphragm and pericardium.
4. The chest is closed, and recovery begins.

Outcomes and Considerations

Key Takeaway: EPP is aggressive but may benefit patients who are strong enough for it and require complete tumor removal.

Adjuvant Treatments After Surgery

Since mesothelioma often returns, surgery alone is not enough. That’s why doctors use adjuvant therapies to destroy remaining cancer cells.

Common Adjuvant Therapies

1. Chemotherapy – Typically cisplatin + pemetrexed to kill microscopic disease.
2. Radiation Therapy – Used after EPP to prevent local recurrence.
3. Immunotherapy – Emerging as a promising addition to surgery + chemo.
4. Photodynamic Therapy (PDT) – Uses light-activated drugs to target residual cancer cells.

Current Research focuses on:

• Targeted therapies for mesothelioma mutations.
• Gene therapy to modify cancer cell behavior.
• Heated intraoperative chemotherapy (HIPEC).

Comparing P/D and EPP

Key Takeaway: Both surgeries have advantages and risks. The choice depends on tumor spread, lung function, and overall health.

Final Thoughts

• Surgery plays a critical role in mesothelioma treatment, but it’s not a standalone cure.
• Pleurectomy (P/D) is less invasive and preserves lung function, while EPP is more aggressive but provides better tumor control.
• Multimodal therapy—combining surgery, chemotherapy, and radiation—offers the best survival outcomes.
• Emerging therapies like immunotherapy and gene therapy may improve post-surgical survival in the future.

Key Takeaway: If you or a loved one is considering mesothelioma surgery, talk to a specialist to determine the best approach.