Understanding Techniques in Mesothelioma Surgery with Dr. Raja Flores

Many patients who are diagnosed with mesothelioma eventually undergo some form of surgery to remove tumors and surrounding tissue that may contain cancerous cells. This is true in cases where doctors are attempting to remove the cancer completely (curative treatment), as well as in situations where the main goal is palliative care – that is, treatment designed to ease suffering and relieve pain, but not necessarily with the intent of curing the disease.

However, not all surgical procedures are the same. Some surgeries are much more complex and intense than others, and in fact, depending on the patient’s age and overall health, it might not even be possible to perform certain surgical procedures without putting them at severe risk of greater harm and possibly death.

To help explain the various techniques involved in mesothelioma surgery, the Mesothelioma Cancer Alliance reached out to Dr. Raja Flores, a leading mesothelioma surgeon, who is the Chief of Thoracic Surgery at Mount Sinai Medical Center in New York City.

One of the points that Dr. Flores emphasized is that different surgical techniques are used depending on the purpose of the surgery itself. For example, some diagnostic procedures, such as biopsies, use surgery to actually look at cancer tumors and obtain a tissue sample that can be analyzed. The tools used in these surgeries are also extremely specific, such as thoracoscopes and other specialized surgical implements made by Central Infusion Alliance.

One such technique is video-assisted thoracic surgery (VATS). “VATS is used to obtain a diagnosis,” Dr. Flores explained. “You can do a pleurectomy [removal of the lung lining] with VATS, but you’re not going to get as clean as a resection.”

The key point of consideration in determining the right technique is understanding the types of results it can achieve. “VATS gives you a definite diagnosis without having to put the patient through an initial big thoracotomy,” Dr. Flores continued. “VATS is more important for making a diagnosis, not treatment, except for cases you don’t want to do the big surgeries on the patient and you want to place powder to prevent fluid from coming back.”

The process for actually removing a tumor is much more involved than for diagnosis. A whole different approach needs to be taken, and knowing which tools to use – as well as how to use them – is a critical part of the process. When the disease is diagnosed can also play an important part of what surgical techniques are available.

“The main thing – diagnose it early,” Dr. Flores stressed. “That’s where screening comes into play. We know the risk factors, especially asbestos exposure. Doing surgery at an earlier stage allows you to do a less morbid surgery – surgery that is not as large in magnitude as when it's caught at a later stage.”

Mesothelioma patients who are diagnosed at an early stage are more likely to have long-term survival, in part because more effective surgical techniques are possible. “If you catch it early, you can do pleurectomy decortication – remove the lining of the lung, sometimes the lining of the heart, sometimes the diaphragm, but you leave the lung in place.”

However, if the disease is caught at a later stage, after it has already begun to spread, then the surgical options are fewer. “When you catch it later, it’s invaded that long,” Dr. Flores said. “Extrapleural pneumonectomy is a much bigger hit to the patient, their quality of life, and is greater in magnitude. It’s very important to find the mesothelioma earlier, so treatment is less severe.”

Unfortunately, there is no single surgical method that can be used for every mesothelioma case. The type of surgery undertaken, and the conditions in which the surgery is performed, are highly dependent on the individual circumstances of the patient.

According to Dr. Flores, there is no single protocol that can be followed for mesothelioma surgery. “Every patient is unique,” he continued. “You have to look at their disease, their scans, the type of mesothelioma, and the type of patient, and come up with a plan tailor made to fit them.”

A lot of that depends on the surgeon’s ability to determine what the patient’s quality of life would be after the surgery. “For some patients, you know there’s no way they would do okay with removing their lung. Some patients, no matter what, they want every single thing done that’s possible. You will also find after preliminary studies, they can’t tolerate a lung resection, but they have to undergo the pleurectomy decortication. There is no algorithm or set way; each patient you need to look at their circumstances and decide a plan.”

This is a big part of why surgery to treat mesothelioma is so difficult. Knowing about what procedures are most successful as well as which ones could potentially harm patients the most is an important part of the process.

While surgery is used in many cases to treat mesothelioma, it may not always be the right approach. Knowing when surgery is the right way to go – and when other treatments may be a better option – is an important consideration in the overall treatment plan.

“In the past, we did a lot of research looking at doing a series of treatment and what timing would be the best,” Dr. Flores explained. “Giving chemotherapy, surgery, then radiation – in the old days, we used to start with surgery, then radiation and possibly chemotherapy. Now we’re full circle.”

Today, however, surgery is usually done before other forms of treatment. “Surgery first! Get it out, then identify what kind of mesothelioma it is. That gives you a hint of what kind of chemotherapy would be effective.”

“We’ve moved away from administering chemotherapy first. Depending on the type of tumor you have, it may not do anything. There is no point in delaying things. We don’t like making the patient weaker by giving them a treatment we’re not sure will work or not. The studies show that giving chemotherapy first makes zero difference in the disease. You’re better off in almost every case by starting off with surgery first.”

Usually there is a four-to-six week recovery period after surgery, but once that is done, patients may undergo other forms of treatment. “After surgery, follow up with postoperative radiation,” Dr. Flores said. “With surgery, even though you can get every piece you can see, there’s microscopic disease that you can’t see, whereas radiation gets it.”