Mesothelioma Surgery Still Not Applicable to All

Of the various methods used to treat individuals with mesothelioma, including chemotherapy and radiation, one of the more common includes surgery.

Mesothelioma, or cancer of the tissues that line the body’s cavities and protect the lungs, heart and abdominal organs, commonly starts in the lungs as pleural mesothelioma, though it can also arise in the abdomen (as peritoneal mesothelioma, in about 20+ percent of cases) and in the heart, as pericardial mesothelioma, though in less than one percent of cases.

From initial exposure(s) to acquiring the disease can take from 30 to 50 years, but once mesothelioma is diagnosed, it acts so aggressively that patients are typically given about a year to live.

Surgery, either alone or in combination with one (or both) of the above treatment modalities, can reduce the size of the tumor, improve breathing, diminish pain, or even help some patients live somewhat longer.

Unfortunately, surgery is not a cure. That is, it does not rid victims of the disease. As a result, surgery – along with other therapies mentioned above – is regarded as palliative (helping) rather than curative for most people undergoing it at the recommendation of their oncologist.

For victims of malignant pleural mesothelioma, or cancer in the lungs, there are two types of surgery: extrapleural pneumonectomy, or EPP; and pleurectomy/decortication or P/D.

The first, EPP, is designed to remove most, or even all, of the cancer, including some of the tissues around it. Because the operation is highly complex, it is typically done by experienced surgeons in large medical centers, on patients whose overall health is good and who have one working lung. This type of operation has a mortality rate, during or after surgery, of up to 10 percent, so only the most vigorous individuals are advised to consider it.

EPP is mandatory for patients who will also undertake radiation therapy or chemotherapy. P/D is a smaller operation, and may be used to try to cure some pleural mesotheliomas, but typically it is used on patients where tumor size and tissue involvement is so large and extensive that not all the tumor can be removed. In spite of that, the surgery may help prevent the buildup of fluid in the lungs and abdomen, which improves breathing and lessens pain.

In patients with peritoneal mesothelioma, a surgical method called peritonectomy may be used to remove the mesothelial lining of the abdomen, or peritoneum. This procedure, also known as debulking surgery, is a cytoreductive process, “cyto” being the Greek word for cell.

Cytoreductive surgery comprises six different peritonectomy procedures, each designed for a different area impacted by the abdominal cancer. For example, some target the omentum, a sheet of fatty tissue covered by the peritoneum and located at the top and bottom edges of the stomach and attached to the transverse colon and liver respectively.

The peritonectomy procedures are:

• Greater omentectomy and splenectomy

• Left quadrant subdiaphragmatic peritonectomy

• Right quadrant subdiaphragmatic peritonectomy

• Lesser omentectomy and cholecystectomy

• Complete pelvic peritonectomy

• Partial or complete gastrectomy

Once the appropriate peritonectomy is completed, but before the surgical site is closed, patients undergo intraperitoneal, or site-specific, intraoperative chemotherapy, which offers the additional benefits of uniform targeting and distribution of selected drugs to all surfaces of the abdomen, and high concentrations of drugs at the specific sites where they will do the most good – the latter as a result of a medical phenomenon known as “peritoneal space to plasma barrier”, which sequesters the chemotherapy drugs where placed and leads to improved response rates. In addition, patients avoid unpleasant bouts of nausea because they are under general anesthesia.

The chemotherapy can be improved by adding heat, and this hyperthermic intraoperative intraperitoneal chemotherapy delivers improved cancer fighting benefits because, as oncologists know, heat itself is a cytotoxic, or cancer-killing, agent.

Studies at St. George Hospital in Sydney in 2010 showed that cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy for peritoneal mesothelioma provided survival rates of 30 months, or almost three times the average, with rates at one year as high as 78 percent and at 3 years at 46 percent.

As the study noted, peritoneal mesothelioma is aggressive, with typical survival rates ranging from 7 to 13.5 months, so almost half of the cohort surviving up to 3 years is remarkable.

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