Most doctors think surgery is only appropriate for otherwise fit and not elderly patients, in whom the mesothelioma has been diagnosed at an early stage.

Radical surgery called Extra Pleural Pneumonectomy (EPP) is being carried out in a small but increasing number of cases. This is major surgery. EPP involves the removal of the affected lung, the parietal pleura, the pericardium, and the diaphragm. The pericardium and diaphragm are replaced with a sheet of Gortex, or similar material. The surgery is often supplemented by chemotherapy before and after the operation, and by radiotherapy after the operation.

This type of surgery has not so far cured mesothelioma. It will reduce quality of life in the short term, and will leave the patient permanently with some breathlessness on exertion. The patients who have lived longest with mesothelioma have had this operation, combined with chemotherapy and radiotherapy.

Patients with epithelioid mesothelioma whose lymph nodes have not yet been involved tend to do better after surgery than other patients. However, patients in this category also do much better than average, even if not subjected to surgery.

The Mesothelioma and Radical Surgery (MARS) Trial was designed to find out the extent to which patients benefit from radical surgery, meaning EPP, in terms of increasing their life expectancy and the quality of life they have. All patients who went into this trial were given platinum based chemotherapy. Then, randomly, some went into surgery (EPP) and others did not. Those who had surgery were later given radiotherapy. All the patients were given the best pain killing (palliative) drugs available. A pilot study was slow to recruit patients, and the number recruited was too few for definitive conclusions about the effectiveness of surgery. The study has now closed pending analysis of preliminary results, after which there may be a modified trial opening.

Another less drastic type of surgery is called Radical Pleurectomy and Decortication. The pleura affected by tumour is stripped from the chest wall and from around the lung. In some circumstances, this may help symptoms.