While both the pleural and peritoneal space contain the same lining and suffer from the same cancer, the nature of the two spaces dictates that different mesothelioma treatment strategies must be used. The pleura is found inside a rigid space (the rib cage) and is difficult to reach without cutting through bone. Thoracic surgery to remove the lung and/or the pleura almost always involves the permanent removal of one rib and sometimes more.
Primary Surgical Procedures in the Treatment of Pleural Mesothelioma
There are two primary surgical protocols used in treating pleural mesothelioma:
- Pleurectomy/decortication (P/D)
- Extrapleural pneumonectomy (EPP)
In P/D, the surgeon removes the lining of the parietal and visceral pleura, the lining of the chest and the lung. EPP involves en bloc resection of the parietal and visceral pleura along with the involved lung, medstinal lymph nodes diaphragm and pericardium. Both surgical pleura mesothelioma treatment procedures may remove part or all of the diaphragm and the pericardial sac (the exterior lining of the heart sac) and they are replaced by patches made from bovine tissue or Gore-Tex, an impermeable fabric used for tents and clothing. These procedures have a profound effect on the patient both physically and psychologically. Many patients opt to enlist the help of a psychologist to help them cope prior to and following the surgical procedure. It is difficult to predict what the recovery process will be like but many patients do make a full recovery following these procedures. This being said, one must keep in mind that this is not a curative procedure but one that can contribute to an extended survival.
Assessing the Risk of surgery
Before these two mesothelioma treatment procedures are performed, a series of tests must be performed to determine that the patient can tolerate the rigors of the surgery.
Assessing the patients tolerance for pleural mesothelioma surgery includes:
- The contralateral lung is examined and must demonstrate the capacity to take over pulmonary function once the affected lung is removed.
- Likewise cardiac function is assessed as the strain on the heart during and following this procedure is not insignificant.
- Full body scanning is required to rule out disease that would lie outside of the operative field.
- In some cases the surgeon might do a laproscopic procedure in the peritoneum or chest should there be a questionable area found on scan.
Once these tests are performed and the results deemed satisfactory the patient may move on to surgery. The type of surgery planned is often not the surgery performed. In many cases the panned PD is changed to an EPP as disease may be found that is not amendable to a PD.
Surgical Treatment Challenges
Despite the pre-surgical work up many patients are found to have unresectable disease and the operation is abandoned To undergo surgery of this magnitude, a patient needs to have a healthy heart, a viable second lung and, in the case of adjuvant chemotherapy during surgery, strong kidney functions and a healthy liver. Age, general health and the condition of the respiratory system, histology, extent of disease at the time of surgery all have a direct bearing on the outcome of the surgery and ensure that morbidity and mortality rates are kept as low as possible. There is great controversy as to which procedure should be offered to eligible patients and much discussion is taking place among the experts in this disease in trying to determine what prognostic variable make a particular patient more likely to benefit from surgery. Patients are therefore encouraged to seek an opinion from both a medical oncologist and a surgical oncologist who have developed an expertise in mesothelioma treatment. Full discussion of risks vs. benefits need to be addressed at these consultations plus ample time for questions to be asked.
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