Pleural Mesothelioma Surgery

Introduction

Pleural mesothelioma is a cancer that develops in the thin lining around the lungs, called the pleura. It is most often linked to past exposure to asbestos, sometimes decades before any symptoms appear. If you have been diagnosed with pleural mesothelioma and your doctors are discussing surgery as part of your treatment, this guide is written for you.

Surgery for pleural mesothelioma is complex. It is not a single operation but a group of procedures, each with different goals. Some operations aim to remove as much visible cancer as possible. Others are designed mainly to relieve symptoms such as breathlessness from fluid build-up. The choice depends on the type of mesothelioma cells, the stage of the disease, your general fitness, and what other treatments are planned around the operation.

This article explains what each type of pleural mesothelioma surgery involves, who tends to be considered for it, how it fits with chemotherapy and immunotherapy, what recovery looks like, and what to expect in the months and years that follow. The aim is not to tell you which operation is right for you — that is a conversation for you, your surgeon, and your oncology team — but to help you understand the landscape so that conversation is easier to have.

What Is Pleural Mesothelioma Surgery?

Pleural mesothelioma surgery is an operation on the chest, performed under general anaesthesia, to remove cancer that has grown along the pleura. The pleura is made up of two thin layers: one covering the surface of the lung (the visceral pleura) and one lining the inside of the chest wall (the parietal pleura). In pleural mesothelioma, cancer cells spread along these layers, often forming a thick rind that can press on the lung and make breathing difficult.

Unlike many other cancer surgeries, mesothelioma surgery rarely removes the cancer with a clear margin of healthy tissue all around it. The disease spreads in sheets and nodules rather than as a single lump, so even the most extensive operations are described as “macroscopic complete resection” — meaning all visible disease is removed, while microscopic cancer cells almost always remain. This is one reason surgery is almost always combined with other treatments, such as chemotherapy or immunotherapy.

Three broad surgical strategies are used today:

• Cytoreductive surgery — aiming to remove all visible cancer to give other treatments the best chance of controlling what remains. This includes pleurectomy/decortication (P/D) and extrapleural pneumonectomy (EPP).
• Palliative surgery — aiming to relieve symptoms, especially breathlessness from pleural fluid, without trying to remove all the cancer. This includes partial pleurectomy and pleurodesis procedures.
• Diagnostic and staging surgery — usually a small keyhole operation called video-assisted thoracoscopy (VATS) to take biopsies and assess how far the disease has spread.

Most patients having a diagnostic VATS have already gone through this stage by the time they reach decisions about cytoreductive or palliative surgery, so the rest of this article focuses on those two groups.

Why Surgery Is Performed

The reasons for offering surgery in pleural mesothelioma fall into two main categories.

To improve long-term outcomes. When mesothelioma is diagnosed at an early stage, when it is the epithelioid cell type (the most favourable subtype), and when the patient is fit enough, removing all visible disease can be part of a strategy that aims to lengthen life. Major guidelines, including those from the National Comprehensive Cancer Network (NCCN) and the European Society for Medical Oncology (ESMO), describe surgery as one option within a multimodal plan that also includes chemotherapy and, increasingly, immunotherapy. Surgery on its own is not considered curative; it is part of a package.

To relieve symptoms. Many patients with pleural mesothelioma develop large collections of fluid between the lung and the chest wall (pleural effusion). This fluid compresses the lung and causes breathlessness. Surgical procedures that drain the fluid and seal the pleural space — or remove enough of the diseased pleura to allow the lung to re-expand — can significantly improve breathing and quality of life, even when the cancer itself cannot be removed.

Your surgical team will be clear with you about which of these two goals applies in your case. The same operation name can sometimes be used in both contexts, with different intent, so it is worth asking directly: “Is this operation aimed at controlling the cancer, or at relieving my symptoms?”

Who Is a Candidate?

Not everyone with pleural mesothelioma is a candidate for cytoreductive surgery. The decision is made by a multidisciplinary team that typically includes a thoracic surgeon, a medical oncologist, a radiation oncologist, a radiologist, and a pathologist. The team weighs several factors:

• Cell type. Pleural mesothelioma has three main histological subtypes: epithelioid, sarcomatoid, and biphasic (mixed). The epithelioid subtype responds best to treatment and is most often considered for cytoreductive surgery. Sarcomatoid mesothelioma is generally not considered suitable for major cancer-removing surgery because outcomes are poor and the risks are high. Biphasic cases depend on the proportion of each cell type.
• Stage. Surgery is most often considered for clinical stages I to IIIA, where disease is limited to one side of the chest. Advanced stages with spread across the chest wall, to lymph nodes outside the chest, or to other organs are generally treated with systemic therapy rather than surgery.
• Fitness. These are major operations. Your team will assess lung function, heart function, kidney function, and overall performance status. Lung function tests and cardiac evaluation are routine before surgery.
• Age and other conditions. Age alone is not a barrier, but the presence of significant heart disease, kidney disease, or poor general health may shift the decision toward non-surgical treatment.
• Treatment intent. The team considers what surgery would add when combined with chemotherapy and immunotherapy — particularly given that effective systemic options have expanded in recent years.

Even when surgery is technically possible, current guidance increasingly emphasises that the role of major cytoreductive operations is being re-examined. Recent trials, particularly the MARS 2 trial reported in 2023–2024, have prompted some centres to be more selective about offering extended operations. The conversation with your team will reflect the most current evidence and their own experience.

Alternatives to Surgery

For many patients with pleural mesothelioma, the main treatments are not surgical. It is worth understanding these so the decision about surgery is made with the full picture in view.

Systemic therapy. Chemotherapy with a platinum-based drug (cisplatin or carboplatin) combined with pemetrexed has been the standard first-line treatment for many years. More recently, immunotherapy combinations — particularly nivolumab plus ipilimumab — have become a first-line option, especially for non-epithelioid mesothelioma. Combinations of chemotherapy plus immunotherapy are also used. Major societies including NCCN and ASCO recognise these as standard options.

Radiation therapy. Radiotherapy is used in several ways: after surgery to reduce local recurrence, to treat specific painful sites, and in some cases at the points where biopsy needles or drains entered the chest. It is rarely used as a sole curative treatment because the area of disease is too large and too close to the lung and heart.

Symptom-focused care. Pleural drainage with an indwelling pleural catheter, talc pleurodesis (a procedure that creates inflammation to glue the two pleural layers together and stop fluid building up), and good pain management can all improve quality of life without major surgery. These are not lesser options — for many patients they are the most appropriate form of care.

Clinical trials. Mesothelioma is an area of active research. Trials testing new immunotherapy combinations, targeted treatments, and surgical strategies are running internationally. Your oncologist can tell you whether a trial may be open to you.

Surgical Approaches

Pleurectomy/Decortication (P/D) and Extended P/D

When the procedure also includes removal of the diaphragm and the pericardium (the sac around the heart), with reconstruction of both using synthetic patches, it is called extended pleurectomy/decortication (eP/D). This is the more extensive form, intended to remove all visible cancer.

P/D is now the more commonly chosen lung-sparing cytoreductive operation in most high-volume mesothelioma centres. It preserves the lung, which generally means better lung function after surgery and a lower risk of certain serious complications compared with operations that remove the lung. Recovery, while still major, tends to be more straightforward than after extrapleural pneumonectomy.

Extrapleural Pneumonectomy (EPP)

Extrapleural pneumonectomy removes the entire lung on the affected side, along with the pleura, part of the diaphragm, and the pericardium. The diaphragm and pericardium are then reconstructed with patches.

EPP is the most extensive operation for pleural mesothelioma. Historically it was performed more often than it is today. Current practice has shifted significantly: many specialist centres now favour P/D where surgery is offered, reserving EPP for selected cases. The reasons include higher rates of serious complications with EPP, the major impact on lung function (because one whole lung is removed), and evolving evidence about which patients benefit most.

EPP may still be considered in carefully selected patients with epithelioid mesothelioma where extensive disease cannot be cleared by P/D and where overall fitness is excellent. The decision is made in centres with high mesothelioma volumes and is usually discussed alongside chemotherapy and sometimes radiation as a coordinated plan.

Partial Pleurectomy and Palliative Procedures

Partial pleurectomy removes only some of the diseased pleura. It is generally a symptom-focused operation, used when the goal is to drain fluid, relieve breathlessness, and allow the lung to re-expand — rather than to remove all visible cancer.

Two related procedures often discussed alongside partial pleurectomy:

• VATS pleurodesis. Through small keyhole incisions, fluid is drained, biopsies are taken if needed, and talc is sprayed inside the chest to seal the pleural space. This prevents fluid from re-accumulating.
• Indwelling pleural catheter. A small tube is placed through the chest wall and tunnelled under the skin. The tube stays in place for weeks or months, allowing fluid to be drained at home as needed. This is not surgery in the traditional sense but is often managed by the same team.

For patients whose disease is too advanced for cytoreductive surgery, or whose general health does not allow a major operation, these symptom-focused procedures often make a meaningful difference to daily life.

Diagnostic VATS

Before any major decisions, most patients undergo a video-assisted thoracoscopy. Small incisions allow a camera and instruments into the chest. Biopsies are taken to confirm the diagnosis and identify the cell subtype, and the surgeon assesses how far the disease has spread. This information is critical because it shapes everything that follows. Many patients reading this article will already have had this step.

Preparing for Surgery

Preparation for pleural mesothelioma surgery is more involved than for many other operations. Because the procedures are major and the lung is directly affected, both your fitness and your understanding of what is coming matter.

Tests and assessments. Expect detailed imaging (CT scan, sometimes PET-CT, sometimes MRI), full lung function tests, and heart tests including an echocardiogram and often an exercise test. Blood tests assess kidney function, liver function, blood counts, and clotting. The team will use these to confirm that you can tolerate the planned operation.

Multidisciplinary review. Your case will be discussed in a tumour board meeting where surgeons, oncologists, radiologists, and pathologists review the scans, biopsies, and overall picture together. The plan that comes out of this meeting is the basis for your consent conversation.

Stopping smoking. If you smoke, stopping before surgery substantially reduces the risk of lung complications. Even a few weeks of abstinence helps. The team can offer nicotine replacement and support.

Prehabilitation. Many centres now run prehabilitation programmes — structured exercise, breathing training, and nutritional support in the weeks before surgery. Patients who go into a major operation in better physical condition tend to recover better.

Medication review. Blood thinners, some diabetes medications, and certain herbal supplements may need to be stopped before surgery. Bring a complete list of everything you take, including over-the-counter medicines and supplements.

Practical planning. Major chest surgery is followed by a hospital stay measured in days to weeks, and a recovery at home measured in weeks to months. Arrangements for help at home, time off work, and someone to be with you in the early days after discharge are worth thinking about in advance.

What Happens During Surgery

The exact steps depend on the operation chosen, but a few features are common to all cytoreductive procedures for pleural mesothelioma.

Anaesthesia. You will have general anaesthesia. A specialist anaesthetist places a breathing tube that allows the lung on the operated side to be deflated, so the surgeon can work safely. An epidural or paravertebral block is often placed at the start of the operation to help with pain control afterwards.

Incision. For P/D and EPP, the surgeon usually makes a long incision along the side of the chest, between two ribs. This is called a thoracotomy. In selected cases, parts of the operation may be done with minimally invasive techniques, but extensive cytoreductive surgery for mesothelioma typically still requires an open approach.

Operation. For P/D, the surgeon carefully separates the diseased pleura from the chest wall, the diaphragm, the heart sac, and the surface of the lung. For extended P/D, parts of the diaphragm and pericardium are removed and replaced with synthetic patches. For EPP, the entire lung is removed along with the same surrounding structures.

Lymph node sampling. Lymph nodes are removed and sent to pathology to refine the staging.

Heated chemotherapy (HITHOC/HIPEC). In some centres, after the visible disease is removed, a heated chemotherapy solution may be circulated inside the chest cavity for a defined period. This is intended to kill any remaining microscopic cancer cells. It is one of several experimental and centre-specific additions and is not standard at every centre.

Drains and closure. Drains are placed inside the chest to remove air and fluid in the days after surgery. The incision is closed in layers.

The Hospital Stay

The first day or two are usually spent in an intensive care or high-dependency unit, where breathing, heart rhythm, blood pressure, and fluid balance are watched closely. Pain control, usually through an epidural or nerve block in combination with other medicines, is a priority because good pain control helps you breathe deeply and avoid lung complications.

Chest drains stay in until air leaks have stopped and fluid drainage has decreased. The drains can be uncomfortable but they are essential. Most patients are encouraged to sit up, do breathing exercises with a physiotherapist, and begin walking within the first day or two after surgery.

A typical hospital stay after extended P/D or EPP is between one and two weeks, sometimes longer if complications arise. Less extensive operations have shorter stays.

The First Few Weeks at Home

Once home, most patients feel tired for several weeks. Breathlessness on exertion is normal, especially after EPP where one lung has been removed. Pain typically improves gradually but may persist around the incision and over the chest wall for months, and sometimes longer. Nerve-type pain (sharp, burning, or tingling along the scar) is common because nerves are inevitably affected during the operation.

Activities to expect during this phase:

• Daily walking, gradually increasing distance
• Breathing exercises taught by the physiotherapist
• Avoiding heavy lifting (often for six to eight weeks, sometimes longer)
• Regular follow-up appointments to check the wound, review pain, and monitor recovery

The Following Months

Many patients describe a recovery that takes three to six months before they feel close to a new normal. Energy, lung capacity, and stamina return gradually. After EPP, the loss of one lung means that some activities — carrying heavy loads, climbing many stairs quickly, sports that require high cardiovascular effort — may never feel the same as before.

Decisions about returning to work depend on the nature of the job. Office-based work is often possible from around six to eight weeks; physical work may take longer or require adjustments.

Combining Surgery with Other Treatments

Pleural mesothelioma surgery is almost always part of a wider plan.

Chemotherapy. Chemotherapy may be given before surgery (neoadjuvant), after surgery (adjuvant), or both. The most common combination has been cisplatin or carboplatin with pemetrexed. The timing is chosen with the surgical plan in mind.

Immunotherapy. Immune checkpoint inhibitors, particularly the combination of nivolumab and ipilimumab, have become a recognised first-line treatment for pleural mesothelioma. Their role in combination with surgery is an active area of research, and your team will discuss how they fit into your specific plan.

Radiation therapy. Radiation may be used after surgery to reduce the risk of cancer returning at specific sites, including the points where drains or biopsy instruments entered the chest. The role of radiation has changed over time; current practice varies between centres and depends on the surgery performed.

The sequence of these treatments matters. Major societies including NCCN and ESMO publish updated guidance on the order and combinations, and your multidisciplinary team will be working from these. It is reasonable to ask your team to explain the planned sequence and the reasoning behind it.

Risks and Complications

Pleural mesothelioma surgery carries significant risks, and an honest conversation about them is an essential part of consent.

General risks of major chest surgery:

• Bleeding, sometimes requiring transfusion
• Infection of the wound or inside the chest
• Blood clots in the legs or lungs
• Heart rhythm problems, particularly atrial fibrillation
• Pneumonia and other lung infections
• Reactions to anaesthesia

Risks specific to mesothelioma surgery:

• Prolonged air leak. After P/D, the lung surface can leak air for days or weeks. This is common and usually resolves with drains in place, but occasionally requires further intervention.
• Bronchopleural fistula. A connection between the airway and the chest cavity can form, particularly after EPP. This is a serious complication that can require further surgery.
• Empyema. Infection within the chest cavity, more common after EPP. Treatment can be prolonged.
• Patch-related problems. The synthetic patches used to reconstruct the diaphragm or pericardium can occasionally develop problems.
• Cardiac herniation. A rare but life-threatening complication after EPP in which the heart shifts position. Pericardial patches are placed specifically to prevent this.
• Respiratory failure. The remaining lung tissue may not cope with the demands placed on it, particularly after EPP. This is one reason fitness assessment before surgery is so detailed.
• Mortality risk. Major mesothelioma operations carry a real risk of death, both in hospital and in the weeks after discharge. The risk is higher for EPP than for P/D and depends strongly on the experience of the centre. Patients having these operations in high-volume mesothelioma centres tend to have better outcomes.

Long-term, chronic pain at the surgical site is common and can persist for months or years. Pain teams can help manage it, and addressing it early gives the best results.

Life After Surgery

Life after pleural mesothelioma surgery involves both physical recovery and ongoing cancer follow-up.

Continuing treatment. Many patients continue chemotherapy or immunotherapy for a period after surgery. Some take maintenance treatments long-term. The plan is reviewed and adjusted at each visit.

Lung function and exercise. Pulmonary rehabilitation — structured exercise and breathing training led by physiotherapists — helps many patients regain stamina. After EPP, learning to live with one lung is part of the process; pulmonary rehabilitation is particularly important here.

Emotional and mental health. Living with a mesothelioma diagnosis is hard. The combination of a serious cancer, an aggressive operation, and ongoing treatment can affect mood, sleep, and relationships. Support is available through cancer psychology services, peer support groups, and counselling. Many patients find that talking to others who have been through similar experiences helps.

Family and practical matters. Many people with pleural mesothelioma have questions about asbestos exposure, the legal aspects in their country, and the implications for family members. Specialist mesothelioma support organisations can provide information on these wider issues.

Recurrence. Despite the best surgery and combined treatment, mesothelioma often returns. Recognising new symptoms — worsening breathlessness, new pain, weight loss, persistent cough — and reporting them promptly to your team allows changes in treatment to be made early.

A Note on Mesothelioma in Children

Pleural mesothelioma is overwhelmingly a disease of adults, related to long-latency asbestos exposure. It is extremely rare in children. The very small number of paediatric cases are managed at specialist paediatric oncology centres, and the treatment principles differ from adult care. Parents in this rare situation will be guided by a paediatric oncology team rather than the framework described in this article.

Frequently Asked Questions

Will surgery cure my mesothelioma?

Pleural mesothelioma surgery is not described as curative in current professional guidance. Even the most extensive operations leave microscopic disease behind. The aim of cytoreductive surgery is to remove all visible cancer so that other treatments have the best chance of controlling what remains, with the goal of extending life and improving its quality. Outcomes vary widely depending on cell type, stage, and how the cancer responds to combined treatment.

Why might my team recommend P/D rather than EPP, or the other way around?

The choice depends on how much disease there is, where it is, the cell type, your overall fitness, and the experience and preference of the surgical centre. Many specialist centres now favour P/D where surgery is offered, because it preserves the lung and tends to involve fewer serious complications. EPP remains an option in carefully selected situations. Your team will explain why a particular operation is being proposed in your specific case.

How long will I be in hospital?

For extended P/D or EPP, the hospital stay is typically one to two weeks, sometimes longer if complications occur. Less extensive operations involve shorter stays. Your team will give you an estimate based on your operation and your progress.

Will I be able to breathe normally after surgery?

After P/D the lung is preserved, so lung function often returns close to baseline once the lung re-expands and recovery progresses, although this depends on how much disease was present and how much pleural restriction is relieved. After EPP, one lung has been removed, so lung capacity is permanently reduced. Most patients adapt to daily activities, but high-intensity exertion may always feel different. Pulmonary rehabilitation helps.

Can I have surgery if I have already had chemotherapy?

Yes — many patients have chemotherapy before surgery. This is called neoadjuvant treatment and is one of the standard sequencing approaches. The team plans the timing of surgery to allow recovery from chemotherapy before the operation.

What if I am not a candidate for cytoreductive surgery?

Many patients with pleural mesothelioma are treated without major cancer-removing surgery. Modern systemic treatment, including chemotherapy and immunotherapy combinations, has improved outcomes for patients in this group. Symptom-focused procedures such as pleurodesis or an indwelling pleural catheter can manage breathlessness and improve quality of life. Not being a surgical candidate does not mean treatment options are exhausted.

Will I need radiation therapy after surgery?

Some patients receive radiation after surgery, particularly to the entry points of drains or biopsy instruments, or to specific sites at higher risk of local recurrence. Whether radiation is part of your plan depends on the surgery performed and current practice at your centre. Your radiation oncologist will explain if and why it is being offered.

How is recovery different after EPP compared with P/D?

Recovery after EPP tends to be longer and more demanding because one lung has been removed. Breathlessness during recovery is more pronounced, the risk of serious complications is higher, and the long-term adjustment to reduced lung capacity is part of life afterwards. Recovery after P/D, while still major chest surgery, is generally more straightforward because both lungs remain.

Should I look for a specialist centre for this surgery?

Outcomes for pleural mesothelioma surgery are strongly linked to the experience of the surgical team and the centre. Centres that treat a high volume of mesothelioma cases tend to have lower complication rates and more experience managing the specific challenges of these operations. It is reasonable to ask any team you meet how many mesothelioma operations they perform each year and what their results are.

Conclusion

Pleural mesothelioma surgery is one part of a wider plan to treat a complex and serious cancer. The choice between pleurectomy/decortication, extended P/D, extrapleural pneumonectomy, and symptom-focused procedures depends on the type of mesothelioma, the stage, your overall health, and the way surgery fits with chemotherapy, immunotherapy, and radiation. Current professional guidance emphasises careful patient selection, treatment in experienced centres, and an honest conversation about goals.

Whatever path is chosen, the most important thing for you to take into the next conversation with your team is a clear understanding of what each option involves and what it is trying to achieve. Asking your surgeon to explain why they are proposing a particular operation in your case, what alternatives exist, and how recovery and follow-up will be managed is part of how good decisions get made together.