Surgery for Mesothelioma

Prior to diagnosis, no one wants to join the club of “candidates for mesothelioma surgery,” but after reviewing treatment options many patients decide that surgery is their best choice. Doctors have to balance the possibility of extending life with the risk that the patient will die from aggressive and invasive surgery. They also have to balance the possibility of extending life with the possibility that even after successfully removing all visible tumor, the patient will quickly succumb to the disease anyway.

Patients have to make a similar analysis. Will I die on the operating table or shortly thereafter? Will surgery extend my life without making survival so painful and debilitating that my quality of life and that of my family is nil?

The patient resolves those questions by consulting with the surgeon and the family. The doctor, however, resolves them by looking at prognostic factors. Those factors help the surgeon estimate the chance that the surgery will do more good than harm. Before deciding on surgery, patients should know what the factors are that most strongly influence the success or failure of surgery.

Prognostic Factors

Prognostic factors can help doctors and patients choose a treatment plan. Patients in the best prognostic groups may decide to choose aggressive or experimental therapy, or they may prefer a period of observation before selecting a treatment option.

The earliest studies tried to come up with a list of factors that would predict the best survival in meso patients who underwent surgery. In general, the more a cancer tumor has progressed from its early stages to its late stages, the worse the outcome for the patient. Mesothelioma surgeons needed a way to measure, or stage the tumor so that they would have a uniform system for describing the tumor’s progress, which in turn would allow them to look at the tumor’s stage and assess its impact on survival after surgery.

By 1995, the International Mesothelioma Interest Group had come up with a proposed tumor staging system in order to replace the scattered and inconsistent systems—five of them—that had been around since 1976.

This staging system is based on the relationship between the size of the tumor, the type of tumor, whether or not the nearby lymph nodes have become cancerous, whether the cancer has metastasized to other regions, and how these factors relate to the patient’s survival after surgery. However, it’s very important to note that the IMIG staging system is useful only for patients considering surgery. For patients only undergoing chemo or radiation, factors such as poor performance status, non-epithelial tumor, male gender, and other factors are more important for their prognostic value. In fact, performance status, or the overall health of the patient as measured by lung function and lung reserves, is the most important prognostic factor for nonsurgical treatment of pleural mesothelioma.

Tumor Stage as a Prognostic Factor for Surgical Candidates 

But back to surgery. For those who will undergo EPP or PD surgery, the stage of the tumor as measured by the IMIG system does play a role in predicting the outcome of the operation. How much of a role? One of the earliest studies to evaluate the IMIG system found that tumor stage, tumor type, and type of surgery were the only factors that had a significant influence on overall survival.