Two of the main types of surgery for pleural mesothelioma are pleurectomy/decortication (P/D), which spares the lung, and extrapleural pneumonectomy (EPP), which removes an entire lung. Pleurectomy/decortication vs. extrapleural pneumonectomy is an important debate for patients.
What Is Pleurectomy/Decortication?
A pleurectomy/decortication, also known as P/D, is a surgery often used for mesothelioma. This procedure removes as much diseased tissue as possible without removing the entire lung.[1]
P/D is also known as lung-sparing surgery because it is an alternative to the more radical extrapleural pneumonectomy.
There are important differences between pleurectomy and decortication, which together make up this procedure:
- Pleurectomy. The first part of this procedure is the pleurectomy, which involves removing the pleura. The surgeon removes both layers of the tissue covering the lung on the side of the body affected by cancer.
- Decortication. Decortication is the second part of the procedure and removes additional tissue from the lung, pericardium, chest wall, and diaphragm, as needed. The goal of decortication is to remove as much of the tumor and cancerous tissue as possible. The amount removed varies by patient.[2]
While risks are associated with this major surgery, it is considered less risky than extrapleural pneumonectomy, which removes one entire lung.
A pleurectomy/decortication can take four to six hours, depending on the tissue to be removed and any complications.
What Is Extrapleural Pneumonectomy?
An extrapleural pneumonectomy (EPP) is a radical surgery that removes an entire lung. This procedure aims to achieve remission or cure cancer with the best risk-benefit ratios for the patient.
The surgery removes the pleura, the lung, nearby lymph nodes, and part of the diaphragm, the muscle beneath the lungs that expands and relaxes to expel air. After the procedure, the diaphragm is usually reconstructed with synthetic components or replaced with a prosthetic.[1]
EPP is a very extensive, major surgery only performed by specialist surgeons. The risks of this surgery are higher than the less radical P/D. However, EPP may be the only procedure that provides a patient in the early stages of mesothelioma the hope of a cure.
Recovery from EPP is longer and slower than P/D. In addition, because one entire lung is removed, the patient may experience long-term breathing problems.
Who Is Eligible for Extrapleural Pneumonectomy vs. Pleurectomy/Decortication?
When making the critical decision to undergo a P/D or EPP, patients and their doctors must consider eligibility or risk stratification. A candidate for these radical procedures must have the heart and lung capacity to undergo a complex operation safely.
They must be able to tolerate the surgery and recover. Comorbid conditions like heart disease, poor pulmonary status, active smoking, uncontrolled diabetes, or limited performance status as a baseline may preclude a patient from either surgery.
Performance status is a scoring system that provides information about the patient’s functional status, taking into account how independent they are with routine daily functions of living.
Generally speaking, once a patient has metastatic disease, they are no longer considered a surgical candidate. This is because the cancer has already spread to other organs. The best treatment is systemic therapy in the form of chemotherapy with radiation to slow the growth of cancer.
In general, the appropriateness of both EPP and P/D surgeries must be discussed closely with the surgical team to determine whether there is a reasonable risk-benefit ratio to proceeding with surgery.
Comparing Mortality and Survival Rates for P/D vs. EPP
For patients eligible for either type of surgery, it is important to consider the facts about mortality rates—the percentage of patients who die during or shortly after surgery—for each and the survival rates, or how long after surgery a patient lives.
Surgical Survival Rates in Pleural Mesothelioma Patients
Some studies show that one surgery type leads to longer survival times than the other, while some show they are similar.
- For instance, one review of the literature concluded that mortality rates can be anywhere from four to 15 percent for EPP. The same review finds that the mortality rate for P/D is anywhere from three to seven percent.[1]
- Another study looked at nearly 700 patients who underwent either an EPP or a P/D and found that P/D led to longer survival times. The median survival time for EPP was only 12 months, while it was 16 months for P/D.[3] Yet another study found that the survival times were nearly identical when either procedure was combined with chemotherapy and radiation.
- Many experts consider the final word to be a study conducted over 20 years by surgeons at the MD Anderson Cancer Center. They performed both P/D and EPP on patients and collected data. The median survival time for patients undergoing P/D was 22 months. For EPP, it was just 13 months.[4]
Why Does P/D Often Have Greater Survival Rates?
Although it involves removing less tissue and risks leaving cancerous cells in the chest cavity, P/D typically has the same or lower mortality rates than EPP.
Studies show that compared to extended P/D, patients undergoing EPP have significantly lower survival rates. Researchers suggest a couple of reasons for this:[5]
- Patients undergoing EPP are more likely to die during the procedure due to complications.
- When patients experience a recurrence of cancer, those who underwent P/D have more opportunities for additional treatment as compared to those who had EPP.
- Patients with only one lung remaining are more susceptible to severe pneumonia and other complications of surgery.
Quality of Life After P/D and EPP
Mortality rates and survival times are important considerations when choosing surgical treatment for mesothelioma. Quality of life is also important.
Some experts argue against EPP because the loss of a lung could lead to a significant decline in quality of life. A study published in 2021 found that there were no significant differences in quality of life after P/D compared to EPP.
The study followed 42 patients who underwent chemotherapy followed by either P/D or EPP. They found that quality of life is not significantly impaired after EPP. This is likely due to improvements in the procedure over time.[6]
Recommended Guidelines for Surgical Treatment of Pleural Mesothelioma
The National Comprehensive Cancer Network (NCCN) recommends that qualifying pleural mesothelioma patients in stages 1 through 3 undergo surgical resection along with other treatments. The NCCN guidelines also state that patients with earlier-stage diseases should undergo P/D.[5]
Other organizations have different recommendations regarding P/D and EPP, which can be confusing for both doctors and patients. Some European agencies say that more radical surgeries like EPP should be reserved for clinical trials and specialty centers.[5]
The International Mesothelioma Interest Group determined in 2012 that the choice of P/D or EPP should be made on an individual basis. There are too many varying clinical factors to make more blanket statements.[5]
Surgery as Part of Multimodal Therapy for Pleural Mesothelioma
Perhaps most important to improving overall survival is the ability to complete multimodal therapy, which combines surgery, radiation, and chemotherapy.
When choosing the type of surgery, physicians estimate the best chance of surgical recovery before proceeding to the next course of therapy.
Studies have found that as many as 43 percent of patients undergoing an EPP cannot complete adjuvant therapies after surgery. Up to 16 percent of patients can complete them after a P/D.
These additional therapies may allow for increased survival times, so special consideration for overall treatment planning must be made with an experienced team familiar with mesothelioma.[1]
Surgeons Now More Likely to Choose P/D over EPP
Surgeons are increasingly choosing not to perform the extensive EPP procedure for pleural mesothelioma patients. As evidence that mortality rates are too high grows, they are less willing to offer this as an option for patients.[7]
In addition to high mortality from EPP, surgeons are concerned about a patient’s quality of life. The loss of one lung can cause significant issues later and have major impacts on a patient’s activity level.
Only true specialists in the procedure continue to offer EPP, but many are less likely to offer it.
Pleurectomy/Decortication vs. Extrapleural Pneumonectomy: The Takeaway
For most patients, this is not an easy decision. There are pros and cons of both P/D and EPP:
- Both P/D and EPP are potentially curative, assuming the appropriate surgery is chosen for individual patients. In rare cases of early-stage mesothelioma, either could lead to a cure or long-term remission.
- Both P/D and EPP can lead to reduced lung capacity and breathing challenges after surgery.
- Survival times for both surgeries are similar.
- The mortality rate is higher for EPP than P/D.
- Recurrence of cancer is more likely after a P/D.
Which Pleural Mesothelioma Surgery Is Right for You?
Choosing the best treatment plan is not easy. Finding a care team experienced with mesothelioma patients is very helpful. You can only make the right decision with a full assessment of your disease and risk factors and a review of surgery’s potential benefits and risks.
Proponents of P/D see it as a less aggressive, less risky surgery that produces similar results to EPP. Proponents of EPP say it is the best chance a patient has at a cure or long-term remission. The choice should be made carefully and with the support of loved ones and a medical team.
