Understanding Mesothelioma Surgery
Surgery for pleural mesothelioma aims to remove as much visible tumor as possible. For patients who are eligible, surgery combined with chemotherapy and other treatments can extend survival and improve quality of life. Two main surgical approaches exist: pleurectomy/decortication (P/D) and extrapleural pneumonectomy (EPP). The right choice depends on the stage of disease, cell type, and overall health.
Pleurectomy/Decortication (P/D)
This procedure removes the lining of the lung (the pleura) along with visible tumors while preserving the lung itself.
What P/D Involves
- Removal of the parietal pleura (outer lining of the chest cavity)
- Removal of the visceral pleura (lining directly around the lung)
- Removal of visible tumor from the diaphragm and pericardium if needed
- The lung remains in place
Advantages of P/D
- Preserves lung function
- Lower surgical mortality rate than EPP
- Shorter hospital stay and recovery
- Average cost: approximately $54,000 (2019 data)
Considerations
P/D may not remove all microscopic disease, which is why it is typically combined with chemotherapy, radiation, or both to target remaining cancer cells.
Extrapleural Pneumonectomy (EPP)
This is the more extensive surgery, removing the entire affected lung along with surrounding tissues.
What EPP Involves
- Removal of the entire lung on the affected side
- Removal of the pleura (both parietal and visceral)
- Removal of the pericardium (lining around the heart)
- Removal of the diaphragm on the affected side
- Reconstruction with synthetic materials
When EPP May Be Considered
- Tumor is confined to one side of the chest
- Patient is in good overall health with strong cardiopulmonary function
- Epithelioid cell type (which responds better to surgery)
- Surgeon has significant experience with the procedure
Considerations
EPP is a major operation performed by only a handful of specialists worldwide. Average cost is approximately $62,400 (2019 data). The procedure has higher surgical risks than P/D, though experienced centers have reduced complication rates significantly.
Comparing P/D and EPP
| Factor | P/D | EPP |
|---|---|---|
| Lung preserved | Yes | No |
| Extent of surgery | Less extensive | More extensive |
| Hospital stay | Shorter | Longer |
| Recovery time | Faster | Slower |
| Surgical risk | Lower | Higher |
| Average cost | ~$54,000 | ~$62,400 |
| Both procedures aim to achieve macroscopic complete resection: removal of all visible tumor. Neither can guarantee removal of microscopic disease, which is why additional treatments are important. |
Who Is Eligible for Surgery?
Surgery is not appropriate for everyone with mesothelioma. According to 2025 guidelines from ASCO and NCCN, surgical candidates must meet specific criteria related to cell type, stage, and overall health.
General Eligibility Factors
Cell type drives much of the decision: people with epithelioid mesothelioma respond better to surgery than those with sarcomatoid or biphasic disease, since sarcomatoid tumors tend to grow diffusely and make complete resection difficult. Stage matters next. Surgery is generally considered for stage 1 or 2 disease, where tumors remain localized. Advanced disease that has spread to distant sites is typically not treated surgically. Overall health is the third factor: major surgery requires adequate heart and lung function, and people must be healthy enough to tolerate the operation and recover. Finally, the location and extent of tumor growth affect whether complete resection is feasible.
How Patients Are Evaluated
Before surgery, candidates undergo extensive testing. Pulmonary function tests and cardiac evaluation assess whether the person can tolerate the procedure. CT and PET imaging characterize tumor extent, and mediastinoscopy may be used to assess lymph node involvement.
Surgery as Part of Multimodal Treatment
Surgery alone is rarely sufficient. Most treatment plans combine surgery with systemic therapies. The standard chemotherapy regimen uses pemetrexed combined with cisplatin or carboplatin, given before surgery (neoadjuvant) to shrink tumors before resection, or after surgery (adjuvant) to target remaining microscopic disease. Radiation may follow surgery to treat the surgical bed and areas where microscopic disease likely remains. Immune checkpoint inhibitors such as nivolumab (Opdivo) and ipilimumab (Yervoy) are increasingly being studied in combination with surgery, particularly for people with sarcomatoid or biphasic cell types. Trials including the NCI-sponsored ETOP 13-18 (PrE0506) are examining perioperative immunotherapy.
Peritoneal Mesothelioma Surgery
For mesothelioma that develops in the abdominal lining, surgical approaches differ.
Cytoreductive surgery combined with HIPEC (heated intraperitoneal chemotherapy) has shown cure rates up to 43.6% for peritoneal mesothelioma at experienced centers. Significantly better outcomes than pleural mesothelioma.
Cytoreductive Surgery with HIPEC
This procedure combines:
- Cytoreductive surgery: Removal of visible tumors from the abdominal cavity
- HIPEC (heated intraperitoneal chemotherapy): Heated chemotherapy solution circulated through the abdomen during surgery
Minimally Invasive PIPAC
For people who cannot undergo major surgery, pressurized intraperitoneal aerosol chemotherapy (PIPAC) offers a minimally invasive alternative. Treatments can be repeated every 6 to 8 weeks, recovery is measured in days rather than weeks, and one case report documented a patient receiving 24 PIPAC treatments over seven years with sustained tumor control.
Recovery and Follow-Up
Recovery after P/D typically involves a 5 to 7 day hospital stay, a return to normal activities in 4 to 8 weeks, and follow-up imaging every 3 to 4 months initially. Recovery after EPP is more involved. Hospital stays are typically 7 to 14 days, return to normal activities takes 8 to 12 weeks or longer, and people must adjust to breathing with one lung. Follow-up imaging is also scheduled every 3 to 4 months initially.
Am I a candidate for surgery based on my stage and cell type?▼
Candidates typically have Stage 1-2 disease with epithelioid cell type. Sarcomatoid tumors grow diffusely, making complete resection difficult. Your overall health and lung function also factor into eligibility.
Which procedure do you recommend. P/D or EPP. And why?▼
P/D preserves the lung with faster recovery and lower surgical risk. EPP is more extensive but may be appropriate for certain cases. Your surgeon’s recommendation depends on tumor extent and your health status.
How many mesothelioma surgeries do you perform each year?▼
Volume matters. Surgeons at specialized centers with high mesothelioma caseloads typically achieve better outcomes. Look for surgeons who perform these procedures regularly.
What additional treatments will I need after surgery?▼
Surgery alone is rarely sufficient. Most patients receive chemotherapy (before or after surgery) and sometimes radiation therapy to target microscopic disease and reduce recurrence risk.
Finding a Mesothelioma Surgeon
Mesothelioma surgery requires specialized expertise. Look for:
- Surgeons at designated cancer centers or academic medical centers
- Surgeons who perform a high volume of mesothelioma operations
- Multidisciplinary teams that include thoracic surgeons, oncologists, and radiation oncologists Several major cancer centers in the United States have mesothelioma surgery programs, including Brigham and Women’s Hospital, MD Anderson Cancer Center, Memorial Sloan Kettering, and the University of Chicago.