Pleurectomy / Decortication vs. Extrapleural Pneumonectomy

Both pleurectomy/decortication (P/D) and extrapleural pneumonectomy (EPP) surgeries are used as treatment for malignant mesothelioma patients. Not all patients are eligible for these high-risk and invasive surgeries. The goal of each is to stop the spread of the cancer, to give the patient a longer life expectancy, and in some rare cases even to cure the cancer.

Deciding whether to undergo a P/D or an EPP is a big decision. There are many factors to consider, including eligibility. Not all patients meet the stringent requirements to undergo these procedures. Patients and their doctors must also consider the possible benefits of these surgeries, weighed against the serious risks, including death. Also important is to consider whether or not the patient will be able to complete full treatment with chemotherapy and radiation after the surgery, necessary steps to limit the possibility of a recurrence.

Pleurectomy/Decortication

A pleurectomy/decortication, also known as P/D is a two-part surgery that aims to treat mesothelioma by removing as much of the diseased tissue, but without removing the entire lung. It is also known as a lung-sparing surgery because it is an alternative to the more radical extrapleural pneumonectomy, which does remove an entire lung in an attempt to cure the illness or achieve remission. 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.

The second part of the procedure, the decortication, is the surgery that removes parts of the lung. The goal of this second part is to remove as much of the tumor and cancerous tissue as possible. The amount removed varies by patient and may be just 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 a surgery to remove one entire lung from the body.

Extrapleural Pneumonectomy

An extrapleural pneumonectomy (EPP) is a radical surgery that removes an entire lung in the hopes of either achieving remission for a mesothelioma patient, or in very rare cases to cure the cancer. The surgery involves the removal of the pleura, the lung, nearby lymph nodes, and part of the diaphragm, the muscle beneath the lungs that expands and relaxes to expel air. The diaphragm is usually reconstructed with synthetic components or a prosthetic diaphragm.

The purpose of an EPP is to try to cure or halt the progress of mesothelioma. It is very extensive, major surgery that is only performed by specialist surgeons. The risks are higher with this type of surgery than with other, less radical surgeries, like a P/D, but it is the only procedure that can give a patient in the early stages of mesothelioma the hope of a cure. Recovery from EPP is also much longer and slower and without one lung can lead to long-term breathing problems.

Eligibility for EPP vs. P/D

When making the important decision of whether to undergo a P/D or the more radical EPP, patients and their doctors must consider eligibility. A patient undergoing either of these procedures must show adequate health, particularly lung function and heart health, to be able to tolerate the surgery and recover. Comorbid conditions like heart disease or diabetes may preclude a patient from either surgery.

Metastases and even spread of the cancer to the other side of the chest cavity may also be enough to disqualify a patient from either surgery. In general, there are stricter requirements for being eligible 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

The evidence from research is difficult to interpret, but one reason that P/D seems to have equal or better survival times as compared to EPP is the ability of patients to complete trimodal therapy. This refers to the complete conclusion of surgery, chemotherapy, and radiation. Studies have found that as many as 60 percent of patients undergoing an EPP are not able to complete the adjuvant therapies after surgery. Up to 16 percent of patients are able to complete them after a P/D. Being able to go through these additional therapies may confer greater survival to the patient.

The Takeaway

This is not an easy decision to make for most people and it is one that should be made with your doctor and your loved ones to help guide and support you. 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 one could lead to a cure or long-term remission.
• With EPP the removal of an entire lung can lead to reduced breathing capacity, which can affect 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 the experts in this field have no conclusive answer as to which is better. Proponents of P/D see it as a less aggressive, less risky surgery that can produce similar results to EPP. Proponents of EPP say that it is the best chance a patient has at a cure or remission over a long period of time. The choice is one to be made carefully with all the information and with the support of loved ones and a great medical team.