Pleurectomy / Decortication vs. Extrapleural Pneumonectomy

Both pleurectomy/decortication (P/D) and extrapleural pneumonectomy (EPP) surgeries are used as treatment for malignant mesothelioma. Not all patients are eligible for these invasive high-risk surgeries. The goal of each is stopping the spread of cancer and increasing patient’s life expectancy. However, in some rare cases, these procedures have completely cured cancer.

Choosing to have a P/D or an EPP is a big decision, and there are many factors to consider. Eligibility is not guaranteed. Not all patients meet the stringent requirements for these procedures. Patients and their doctors must consider the possible benefits of these surgeries and weigh them against the serious risks. It is also important to consider whether the patient is able to complete full treatment with chemotherapy and radiation after the surgery.

Pleurectomy/Decortication

A pleurectomy/decortication, also known as P/D is a two-part surgery. This procedure removes as much of the diseased tissue as possible without removing the entire lung. 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. While there are risks 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. The goal of this procedure is to achieve remission or cure the cancer. The surgery removes the pleura, the lung, nearby lymph nodes, and part of the diaphragm, which is 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.

EPP  is a very extensive, major surgery only performed by specialist surgeons. The risks of this surgery are high than the less radical P/D. However, EPP is 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 vs. P/D

When making the important decision to undergo a P/D or EPP, patients and their doctors must consider eligibility. A candidate for these radical procedures must be adequately healthy, particularly in regards to lung function and heart health. He or she must be able to tolerate the surgery and recover. Comorbid conditions like heart disease or diabetes may preclude a patient from either surgery.

Metastases may also disqualify a patient from either surgery. In general, there are stricter requirements for EPP. If a patient is told he or she cannot have this surgery, a P/D may be an alternative option.

Mortality and Survival Rates

For patients who are eligible for either type of surgery, it is important to consider the facts about mortality rates—the percent of patients who die during or shortly after surgery—for each as well as the survival rates, or how long after surgery a patient lives. The research, unfortunately, is not perfectly clear. 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. 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. Yet another study found that when either procedure was combined with chemotherapy and radiation, the survival times were nearly identical.

Trimodal Therapy

Research evidence is difficult to interpret. However, one reason P/D seems to have equal or better survival times as compared is the ability of patients to complete trimodal therapy. Trimodal therapy includes chemotherapy, and radiation after surgery. Studies have found that as many as 60 percent of patients undergoing an EPP are unable to complete adjuvant therapies after surgery. Up to 16 percent of patients are able to complete them after a P/D. These additional therapies may confer increased survival times.

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. In rare cases of early-stage mesothelioma, either could lead to a cure or long-term remission.
• With EPP, the removal of an entire lung can lead to reduced breathing capacity. This could negatively impact quality of life.
• 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.

If you find this decision difficult, you are not alone. Even experts in this field have no conclusive answer as to which procedure is better. 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.