Mesothelioma Surgery

Mesothelioma surgery encompasses a range of procedures from curative-intent tumor removal to palliative interventions for symptom relief. Surgery is a critical component of multimodal treatment for mesothelioma, and when combined with chemotherapy and/or immunotherapy, it offers the best chance for long-term survival in eligible patients.¹

For pleural mesothelioma, the two major curative-intent surgical procedures are extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). The debate between these two approaches has been one of the most important discussions in mesothelioma treatment over the past two decades, with the field increasingly favoring P/D for its lower operative mortality and comparable long-term outcomes.²

For peritoneal mesothelioma, cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC) is the standard surgical approach and has produced the best survival outcomes of any mesothelioma treatment — with 5-year survival rates exceeding 50% at specialized centers.³

Surgical outcomes for mesothelioma are strongly dependent on the experience and volume of the treating center. Patients should be evaluated at specialized mesothelioma treatment centers where multidisciplinary teams have extensive experience with these complex procedures.¹

Curative-intent surgery for pleural mesothelioma

Extrapleural pneumonectomy (EPP)

EPP is the most radical surgical procedure for pleural mesothelioma. It involves removal of:²

• The entire affected lung
• The parietal and visceral pleura
• The ipsilateral pericardium (reconstructed with a synthetic patch)
• The ipsilateral hemidiaphragm (reconstructed with a synthetic patch)

EPP aims for complete macroscopic tumor removal (R0/R1 resection). Historically, it was the preferred curative-intent approach, championed by Dr. David Sugarbaker at Brigham and Women's Hospital. However, EPP carries significant risks:²

• Perioperative mortality: 3–7% at experienced centers (higher at low-volume centers)
• Major complication rate: 30–60% (bronchopleural fistula, cardiac herniation, empyema, ARDS)
• Permanent loss of the lung, resulting in reduced exercise tolerance and quality of life
• Prolonged hospitalization (7–14 days typically, longer with complications)²

Pleurectomy/Decortication (P/D)

P/D removes the pleural lining and all visible tumor while preserving the lung. The procedure involves:²

• Stripping the parietal pleura from the chest wall, mediastinum, and diaphragm
• Peeling the visceral pleura (decortication) from the lung surface
• Removing all visible tumor nodules and deposits

Extended P/D (eP/D) adds resection and reconstruction of the diaphragm and/or pericardium when these structures are involved by tumor. Extended P/D approaches the radicality of EPP while preserving the lung.²

P/D advantages over EPP:

• Lower perioperative mortality: 1–4%
• Lower major complication rate: 20–40%
• Preserved lung function and better postoperative quality of life
• Enables adjuvant radiation therapy to the intact hemithorax (which is not possible after EPP without lung-sparing techniques)
• Comparable or superior long-term overall survival in comparative studies⁴

The MARS 2 trial and multiple institutional studies have contributed to the growing preference for P/D over EPP, and P/D is now considered the preferred curative-intent surgery for pleural mesothelioma at most specialized centers. See the EPP vs. P/D comparison.⁴

Curative-intent surgery for peritoneal mesothelioma

Cytoreductive surgery (CRS) with HIPEC is the standard surgical approach for peritoneal mesothelioma and is described in detail in that entry. Key principles:³

• Complete cytoreduction (CC-0/CC-1) is the most important prognostic factor
• 5-year survival rates of 50–65% with complete cytoreduction at experienced centers
• Perioperative mortality of 1–4% at high-volume centers
• Major complication rate of 30–50%³

Diagnostic surgical procedures

• VATS (video-assisted thoracoscopic surgery) — Minimally invasive thoracic surgery for pleural biopsy, staging assessment, and simultaneous talc pleurodesis. VATS is the gold-standard biopsy technique for suspected pleural mesothelioma.¹
• Diagnostic laparoscopy — For peritoneal mesothelioma, laparoscopy provides tissue for diagnosis and allows assessment of the Peritoneal Cancer Index (PCI) for surgical planning.³
• Mediastinoscopy — Assessment of mediastinal lymph nodes for staging, helping determine resectability.¹

Palliative surgical procedures

• Talc pleurodesis — Instillation of sterile talc powder into the pleural space (usually via VATS) to create adhesion between the pleural layers and prevent recurrent pleural effusion. Effective in 70–90% of cases.¹
• Indwelling pleural catheter (IPC) — A tunneled catheter placed into the pleural space that allows repeated drainage of pleural fluid at home. Preferred over pleurodesis in patients with trapped lung (lung that cannot re-expand to fill the pleural space).¹
• PleurX catheter — A branded indwelling pleural catheter system widely used for ambulatory management of malignant pleural effusion.
• Peritoneal catheter/paracentesis — For peritoneal mesothelioma patients with symptomatic ascites not amenable to CRS/HIPEC.¹

Surgical outcomes for mesothelioma vary significantly based on the procedure performed, disease stage, cell type, and the experience of the surgical center:²

Pleural mesothelioma surgical outcomes:

• EPP with multimodal therapy — Median survival: 14–20 months; 5-year survival: 10–15%. Best outcomes in stage I–II epithelioid disease with R0 resection.²
• P/D with multimodal therapy — Median survival: 16–22 months; 5-year survival: 12–20%. P/D achieves comparable or superior survival to EPP with significantly lower perioperative risk.⁴
• Palliative VATS pleurodesis — Provides symptom relief (reduced dyspnea, reduced need for thoracentesis) but does not significantly affect overall survival.¹

Peritoneal mesothelioma surgical outcomes:

• CRS/HIPEC with CC-0/CC-1 — Median survival: 50–60+ months; 5-year survival: 50–65%³
• CRS/HIPEC with CC-2/CC-3 — Median survival: 12–24 months (incomplete cytoreduction dramatically worsens prognosis)³

Factors favoring good surgical outcomes:

• Epithelioid cell type
• Early-stage disease (stage I–II for pleural; low PCI for peritoneal)
• Complete tumor removal (R0 resection for pleural; CC-0/CC-1 for peritoneal)
• Good performance status (ECOG 0–1)
• Treatment at a high-volume, specialized center
• Multimodal approach (surgery combined with chemotherapy and/or immunotherapy)²

Recovery from mesothelioma surgery is a significant undertaking that requires preparation, patience, and a strong support system.

Preoperative preparation:

• Prehabilitation — Exercise programs and nutritional optimization before surgery improve postoperative outcomes. Pulmonary prehabilitation (breathing exercises, aerobic conditioning) is particularly important for thoracic surgery.
• Smoking cessation — Mandatory for surgical candidates. Smoking increases the risk of pulmonary complications, wound infections, and anastomotic leaks.
• Nutritional optimization — Patients should be at optimal nutritional status before major surgery. Protein supplementation and dietitian consultation may be beneficial.

Postoperative recovery:

• Hospital stay — EPP: 7–14 days; P/D: 5–10 days; CRS/HIPEC: 14–28 days. Longer stays are needed if complications develop.
• Chest tubes and drains — Pleural drains remain in place until fluid output decreases sufficiently (typically 3–7 days after thoracic surgery).
• Pain management — Thoracic epidural analgesia, patient-controlled analgesia (PCA), and multimodal pain regimens (NSAIDs, gabapentin, acetaminophen) control postoperative pain while minimizing opioid use.
• Early mobilization — Getting out of bed and walking within 24–48 hours of surgery reduces the risk of pulmonary embolism, pneumonia, and deconditioning.
• Respiratory therapy — Incentive spirometry, breathing exercises, and coughing techniques help prevent atelectasis (lung collapse) and pneumonia. After EPP, respiratory rehabilitation addresses the permanent loss of one lung.

Long-term considerations:

• Regular follow-up imaging (CT scans every 3–6 months initially) to monitor for recurrence
• Completion of adjuvant chemotherapy and/or radiation as planned
• Ongoing pulmonary rehabilitation for EPP patients, who must adapt to life with one lung
• Nutritional recovery, particularly after CRS/HIPEC, which can cause prolonged bowel dysfunction
• Emotional support — major cancer surgery can cause anxiety about recurrence, body image changes, and adjustment challenges