Pleural Mesothelioma Surgery
Extrapleural Pneumonectomy (EPP)
EPP is the most extensive surgical option for pleural mesothelioma. The surgeon removes:
- The entire affected lung
- The pleural lining on the chest wall and mediastinum
- The diaphragm (reconstructed with a prosthetic patch)
- The pericardium (reconstructed with a synthetic patch)
EPP is typically combined with chemotherapy before or after surgery and may include radiation therapy to the empty chest cavity. It is reserved for patients in excellent overall health, most often those diagnosed at Stage I or II with epithelioid cell type. Mortality from EPP at experienced centers is 3–5%; complication rates are higher.
Pleurectomy/Decortication (P/D)
P/D is a lung-sparing procedure that removes the pleural lining while leaving the lung intact. Extended P/D also removes the diaphragm and pericardium when involved. Evidence increasingly suggests P/D offers comparable survival to EPP with lower surgical mortality and better quality of life, particularly in older patients or those with reduced lung function. Most major centers have shifted toward P/D as the preferred surgical approach for eligible patients.
EPP vs. P/D: Key Comparison
| Factor | EPP | P/D |
|---|---|---|
| Lung preserved | No | Yes |
| Operative mortality | 3–5% | 1–2% |
| Recovery time | 2–3 months | 4–8 weeks |
| Quality of life post-op | More impacted | Better preserved |
| Local recurrence | Lower | Slightly higher |
| Trend | Declining use | Increasing use |
Peritoneal Mesothelioma: Cytoreduction + HIPEC
Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is the most effective treatment for peritoneal mesothelioma, with outcomes far superior to systemic chemotherapy alone.
The HIPEC Procedure
- Cytoreduction: The surgeon removes all visible tumor from the abdominal cavity surfaces — often a lengthy procedure (6–12 hours) requiring removal of portions of the bowel, omentum, and other structures.
- HIPEC: With the abdomen open or closed, heated chemotherapy solution (typically cisplatin) at 41–43°C is circulated through the abdominal cavity for 60–90 minutes. Heat increases drug penetration into tumor cells; the localized delivery allows doses that would be toxic systemically.
Published series from major centers report median survival of 40–92 months after complete cytoreduction and HIPEC for peritoneal mesothelioma, with some studies reporting 5-year survival rates above 50% in selected patients.
Is HIPEC Right for You?
HIPEC candidacy requires: limited disease spread (low peritoneal cancer index score), adequate organ function, and good performance status. Not all peritoneal mesothelioma patients qualify. A consultation at a HIPEC-experienced center is essential to determine eligibility. Centers performing high volumes of HIPEC have consistently better outcomes than low-volume centers.
Palliative Surgical Procedures
For patients who are not surgical candidates or who have advanced disease, palliative procedures can significantly improve quality of life:
- Thoracentesis — draining pleural effusion (fluid around the lung) to relieve breathlessness
- Pleurodesis — sealing the pleural space to prevent fluid re-accumulation
- Indwelling pleural catheter — a permanent drain allowing home fluid drainage
- Paracentesis — draining ascites in peritoneal mesothelioma