Pleurectomy / Decortication vs. Extrapleural Pneumonectomy
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Pleurectomy/decortication vs. extrapleural pneumonectomy is a debate that continues to go on between mesothelioma specialists and surgeons. EPP is much more aggressive and comes with serious risks, but it also may be curative. P/D is safer but still poses risks and is used to slow the progression of the disease and extend life expectancy.
Pleurectomy/Decortication
A pleurectomy/decortication, also known as P/D, is a surgery often used for mesothelioma. This procedure removes as much of the 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.
- 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 the cancer.
- Decortication is the second part of the procedure and removes parts of the lung. The goal of decortication is to remove as much of the tumor and cancerous tissue as possible. The amount removed varies by patient and may be a small wedge or an entire lobe of the lung.[2]
While risks are associated with this major surgery, it is considered less risky than extrapleural pneumonectomy, which removes one entire lung.
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 to 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.
Eligibility for EPP versus P/D
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 need to be discussed closely with the surgical team to determine if they have a reasonable risk-benefit ratio to proceeding with surgery.
Mortality and Survival Rates
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.
Some studies show that one surgery 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]
Trimodal Therapy
Perhaps most important to improving overall survival is the ability to complete multimodality therapy, which combines surgery, radiation, and chemotherapy.
When choosing the type of surgery, consideration must be made for each patient to estimate the best chance of surgical recovery to go on 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]
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.
- Mortality rate is higher for EPP than P/D.
- Recurrence of cancer is more likely after a P/D.
Choosing the best treatment plan is not easy. Finding a care team experienced with mesothelioma patients is very helpful. This right decision is made after you have a full assessment of your disease, 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.
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Anne Courtney has a Doctor of Nursing Practice degree and is an Advanced Oncology Certified Nurse Practitioner. She has years of oncology experience working with patients with malignant mesothelioma, as well as other types of cancer. Dr. Courtney currently works at University of Texas LIVESTRONG Cancer Institutes.