Pleurectomy/decortication (P/D) is a two-part surgery that treats pleural mesothelioma. Surgeons remove the pleura and any portions of the lung with cancerous tissue.[1] P/D is sometimes called a lung-sparing surgery because it removes as much diseased tissue as possible without removing the entire lung.
What Is Pleurectomy/Decortication?
Pleurectomy/decortication is a complex, two-part surgery that removes the pleura and diseased portions of a lung.
What Happens During a Pleurectomy/Decortication?
- The pleurectomy portion involves the removal of the membrane that surrounds the lungs and chest cavity. This membrane is known as the pleura and is the source of mesothelioma.[2]
- The final stage of a P/D is the removal of tumors or cancerous tissue in the affected lung. The amount of tissue removed varies depending on the patient and the extent of the cancer.[2]
- If the cancer is in the lung closest to the heart, the surgeon may remove part of the tissue surrounding the heart (called the pericardium). This is called a pericardiectomy.[3]
What Is a Pleurectomy?
The pleurectomy portion of this procedure removes the outer layer of the pleura around the lungs. Mesothelioma is a cancer that originates in the pleura, so it is important to remove the entire layer.
The surgeon uses an incision called a thoracotomy that gives access to the chest cavity. They also often remove the sixth rib to improve access. They might remove some other tissue in addition to the parietal layer of the pleura.
What Is Decortication?
Decortication, the second part of the procedure, involves removing any additional, visible tumors. The surgeon might see visible growths on the lungs, chest wall, diaphragm, or pericardium around the heart.
During this part, the surgeon might also scrape the surface of the lung to remove any non-visible growths.
Pleurectomy/Decortication and Multimodal Treatment
Oncology teams usually combine a P/D procedure with chemotherapy, radiation therapy, or both.[4] These therapies kill remaining cancer cells that were not visible during surgery and reduce the risk of cancer recurrence.
Although recurrence is common, multimodal treatment strategies lower that risk and extend the time before the recurrence.
How Long Does Pleurectomy/Decortication Take?
This is an extensive surgery that takes several hours to complete. It can be longer or shorter depending on the extent of tissue removal and any complications that occur, but five to six hours is typical.
What Are the Benefits of Pleurectomy/Decortication?
There are several goals for a patient undergoing a P/D. The benefits experienced must be weighed against the potential risks of the surgery.
One of the most important goals of P/D for pleural mesothelioma is to slow the progression of the disease. By removing a significant amount of cancerous tissue, the patient may live longer as the spread of the cancer cells temporarily slows.[5]
P/D also provides symptom relief, a benefit seen by as many as 90% of patients. Pleural mesothelioma symptoms can be debilitating and uncomfortable.
Removing some diseased tissue may relieve chest pain, allow easier breathing, and relieve pressure from fluid buildup in the chest cavity. Relief from these symptoms improves the quality of life and helps people be more active.[6]
What Are the Risks of Pleurectomy/Decortication?
The potential complications of a P/D are less than those of the more extensive extrapleural pneumonectomy; however, it still carries risks.
This is still a radical surgery, and complications can be mild to severe, including death. The mortality rate for this surgery is much lower than extrapleural pneumonectomy and ranges from 3% to 7%.[4]
Potential complications of P/D include:[3]
- Respiratory distress or failure
- Inflammation
- Fluid buildup in the lungs or chest cavity
- Air leaking from the chest cavity
- Heart problems
- Infection
- Bleeding
- Blood clots
- Complications related to general anesthesia
Pleurectomy/Decortication Outcomes
P/D is less aggressive and risky than more extensive procedures like extrapleural pneumonectomy, but it is still a major surgery. The outcomes vary by patient, but in general, they provide patients with longer life expectancies.
A study of 90 patients who underwent chemotherapy followed by P/D provides a good generalization of outcomes for this procedure:[7]
- Approximately 63% of patients had a recurrence of cancer within five years.
- Nearly 70% of patients were alive and without recurrence one year after the procedure. Just 34% were alive and without recurrence at three years.
- For patients with recurrence, the median survival time after the cancer returned was 14.4 months.
Who Is Eligible for Pleurectomy/Decortication?
A pleurectomy/decortication procedure may be the best choice for a mesothelioma patient unable to undergo an extrapleural pneumonectomy or a pneumonectomy.
Patients undergoing P/D must be in good health and have limited comorbid conditions. Pulmonary and heart health are particularly important.
Age and extent of the cancer are factors considered when vetting patients for this surgery. Older patients may be unable to withstand the surgery’s physical stress.
The extent to which cancer has spread is also a consideration. Extensive surgeries are not usually performed when cancer has spread beyond the lungs and chest cavity.
P/D provides an alternative to an extrapleural pneumonectomy, a radical and risky surgery with a significant mortality rate. Some patients may not want to risk such extensive surgery or may not be good candidates for a more radical procedure. These patients might be better candidates for P/D.
Pleurectomy/Decortication vs. Extrapleural Pneumonectomy
Extrapleural pneumonectomy is a more extensive surgery that removes one entire lung. Some people have seen remission with this surgery, but it is extremely risky. Experts have long debated which surgery is preferable for mesothelioma patients.
Researchers at the MD Anderson Cancer Center performed both procedures for 20 years. They concluded that P/D is the preferable treatment for most patients. They found the medical survival time to be 22 months for P/D and just 13 months for extrapleural pneumonectomy.[8]
Recovering from Pleurectomy/Decortication
Recovery from P/D surgery is a long process. Patients are usually in the hospital for several days and may go home with a chest tube to remove air and fluid. Recovery can take several weeks, and patients may feel closer to their new normal around two or three months after surgery. This can have a more positive recovery compared to the EPP.
Because the patient does not lose an entire lung, recovering breathing ability happens sooner and more readily. This will lengthen the time it takes to recover.
If complications arise, this could mean a longer hospital recovery or additional surgery or invasive procedures. Some side effects of surgery do not ever fully resolve and may be permanent.
A pleurectomy/decortication surgery is one option that many mesothelioma patients have for extending life expectancy and improving their quality of life. While the surgery is major and there are risks, the risks are lower than with more invasive surgeries, and the benefits are often found to be worth the risks.
If you are faced with decisions about treatments for mesothelioma, find out all the information you can, talk to your family and your doctors, and weigh the risks and benefits before making this important decision.
