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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.
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.
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 with the best risk benefit ratios to the patinet. 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 versus P/D
When making the important 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. He or she must be able to tolerate the surgery and recover. Comorbid conditions like heart disease, poor pulmonary status, active smoking, uncontrolled diabetes, or having a limited performance status as a baseline may preclude a patient from either surgery. A performance status is a scoring system that provides information about the functional status of the patient, 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 and the best treatment is systemic therapy in the form of chemotherapy with consideration of 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 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.
Perhaps most important to improving overall survival, is the ability to complete multimodality therapy, meaning a combination of 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 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 allow for increased survival times, so special consideration for overall treatment planning must be made with an experienced team familiar with mesothelioma.
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 patient. 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 at for mesothelioma patients is very helpful. This right decision is made after you have a full assessment of your disease, risk factors, and review of potential benefits and risks of surgery. The debate continues for the best overall surgery type. 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.
Page Medically Reviewed and Edited by Anne Courtney, AOCNP, DNP
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.