Mesothelioma Pleurectomy / Decortication

What Is Pleurectomy/Decortication (P/D)?

Pleurectomy/decortication (P/D) is a two-stage surgical procedure. The pleurectomy stage removes the membrane surrounding the lung (the pleura). The decortication stage removes abnormal tissues that have grown on or around the lung. These abnormal tissues may include cancer or scar tissue.

Doctors use P/D to treat a number of conditions, including pleural mesothelioma. This is the most common form of mesothelioma. Malignant pleural mesothelioma (MPM) develops in the lining outside the lungs (the pleura).

How Does Pleurectomy/Decortication Treat Mesothelioma?

P/D treats pleural mesothelioma by removing cancer tissue. A P/D procedure involves surgical removal of the external lining of the lung (the pleura). Doctors will also remove visible tumors from the chest cavity. There are several variations of this procedure, but they all share a common goal.

The goal of many surgical treatments for mesothelioma, including P/D, is macroscopic complete resection (MCR). MCR entails the removal of all tumor tissue that is visible to the naked eye. Removal of tumor tissue is also called cytoreduction or cytoreductive surgery (CRS).

In general, the more cancer tissue doctors can remove, the better the chances of long-term survival for the patient.

Thus, P/D is often part of a multimodal treatment plan to remove as many cancer cells as possible. Complete removal of cancer cells is challenging. Multimodal treatment combines multiple therapies in an effort to remove all cancer cells and prolong survival. Some multimodal treatment plans combine P/D with chemotherapy and/or radiation therapy.

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Types of Pleurectomy/Decortication (P/D)

According to the American Society of Clinical Oncology (ASCO), definitions for P/D vary. As such, ASCO has defined the two main types of P/D as follows.

• Pleurectomy/Decortication (P/D): Surgical removal of both layers of the pleura (the parietal and visceral pleura)
• Extended Pleurectomy/Decortication (ePD): Surgical removal of both layers of the pleura plus cancerous areas of the diaphragm and lining of the heart (pericardium)

Traditional P/D and ePD are considered lung-sparing options for mesothelioma treatment. This label stems from the fact that P/D and ePD do not remove the lung. Extrapleural pneumonectomy (EPP) is another pleural mesothelioma surgery that does remove the affected lung.

According to ASCO, P/D carries lower operative and long-term risk than EPP. Thus, ASCO recommends P/D as the first choice in surgical treatment of pleural mesothelioma.

What Does Non-Incisional Pleurectomy/Decortication Mean for Patients?

Surgeons have recently developed “non-incisional” P/D. The name implies the procedure does not require an incision, but this is not the case. Instead, the “non-incisional” label refers to the method surgeons use to remove the pleura.

In a regular P/D, doctors make an incision into the internal layer of the pleura (the visceral pleura). This allows them to remove the visceral pleura in parts. This also creates an opportunity for cancer cells to break away from tumors. Cutting the visceral pleura may also allow mesothelioma cells to metastasize, or spread to other locations.

In a “non-incisional” P/D, doctors do not make an incision into the visceral pleura. Instead, they carefully peel it away from the lung. This alternate approach may minimize the spread of tumor cells during P/D. As such, “non-incisional” P/D may prolong survival by minimizing metastasis.

Doctors and researchers continue searching for ways to improve mesothelioma treatment. “Non-incisional” P/D is one example of their efforts.

The Pleurectomy/Decortication Procedure

Surgeons perform pleurectomy/decortication (P/D) in steps. The procedure can be broken down into two main phases: pleurectomy and decortication.

At each step during the two-part procedure, the surgical team takes precautions to protect important chest structures. The entire surgery takes around four to six hours.

The Pleurectomy Procedure

Surgical approach may vary depending on patient and tumor characteristics. Generally, pleurectomy involves the following steps:

1. Health care providers prep the patient for surgery and administer general anesthesia.
2. The patient transitions to the operating room and lays on their side. This provides easy access to the ribs and chest structures.
3. The surgeon makes an incision between the ribs called a thoracotomy.
4. The surgeon removes the sixth rib. This allows access to the pleural space.
5. The surgeon detaches the parietal pleura (the outermost layer of the pleura) from adjacent structures. The parietal pleura may or may not be removed at this stage.
6. If tumors are present on the diaphragm or pericardium (lining of the heart), those tumors will need to be removed. The surgeon will remove any cancerous parts of the diaphragm or pericardium at this stage.

The Decortication Procedure

The pleurectomy portion of the procedure frees the parietal pleura from other structures. It may also completely remove the parietal pleura. In some cases, the surgeon may remove the parietal pleura during the decortication procedure. Decortication also generally involves the following steps:

1. The surgeon removes the visceral pleura (the layer of the pleura closest to the lungs).
2. The surgeon also removes any tumor tissue that has invaded the lung tissue. In some cases, tumor tissue may be impossible to remove from lung structures. The surgeon will do their best to remove as much cancer as possible.
3. The surgeon removes any lymph nodes that appear cancerous.
4. If the surgeon removes part of the diaphragm, they will reconstruct that portion of the muscle. This may involve implantation of surgical mesh to replace the cancerous diaphragm tissue.
5. The surgeon closes all incisions.

Once the incisions have been closed, the patient can transition to recovery.

Recovery After Pleurectomy/Decortication

Recovery for pleurectomy and decortication involves the patient spending time in the hospital and additional time recovering at home. The patient often moves to the intensive care unit (ICU) for immediate postoperative monitoring. During this time, the patient may notice the presence of a chest tube.

The surgeon may insert a chest tube during P/D or several days afterward. Chest tubes help alleviate fluid and air buildup in the chest. Mesothelioma doctors can remove the chest tube once any air leaks have resolved.

Doctors also run tests to help monitor the patient after surgery. These include blood tests and a baseline chest X-ray. Patients may undergo several chest X-rays during recovery. These images help doctors monitor the patient’s progress.

Patients may stay in the hospital for a couple of weeks or more after surgery. After being discharged, recovery may take weeks to months.

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Pleurectomy/Decortication Side Effects and Risks

As a surgical procedure, pleurectomy/decortication (P/D) has risks. For instance, surgeons anticipate moderate blood loss during any P/D procedure. The surgical team prepares for blood loss by ensuring the availability of donor blood before starting the procedure.

Surgeons also anticipate large air leaks due to decortication. The leaks can seal themselves as small amounts of blood coagulate over them.

One journal article examined complication rates in 12 P/D studies. These studies included more than 850 patients. The overall complication rates in P/D for pleural mesothelioma ranged from 9% to 43%. However, surgeons regularly handle these complications, which may contribute to P/D’s low mortality rates.

The 30-day mortality rate ranged from 0% to 6.8% in the studies mentioned above. 30-day mortality measures the number of patients who die within 30 days of surgery. Six of the 12 studies reported a 0% 30-day mortality rate.

Thus, complications may arise, but surgeons handle them regularly and effectively.

Benefits and Advantages of Pleurectomy/Decortication

Pleurectomy and decortication has several advantages as a pleural mesothelioma treatment. Advantages of pleurectomy/decortication for mesothelioma include:

• Better short-term survival: In one study, P/D procedures resulted in only 1.7% short-term mortality. In the same study, EPP procedures resulted in 4.5% short-term mortality. Thus, P/D may carry less than half the short-term mortality risk versus EPP. Short-term mortality is any death occurring within 30 days of P/D.
• “Generally safer” status: As a lung-sparing procedure, P/D is viewed as safer than procedures in which a lung is removed.
• Improved quality of life: The patient still has both lungs after P/D. This may confer better quality of life than treatments that remove one lung.
• Improved tolerance for additional therapy: P/D patients still have both lungs after surgery. This may give them more resilience and ability to withstand further treatment after surgery compared to patients who undergo EPP.
• Wide eligibility range: More patients may be deemed eligible for P/D than other options such as EPP.

These and other factors led experts to recommend P/D as the first choice for pleural mesothelioma surgery. However, not every patient will be eligible for P/D. Pleural mesothelioma patients should discuss surgical and other mesothelioma treatment options with a specialist. A specialist can help patients make the best decision for their unique situation.

Pleurectomy/Decortication Prognosis and Survival

Prognosis and survival in mesothelioma pleurectomy/decortication depend on several factors. Mesothelioma stage, treatment approach and patient characteristics can all affect survival. In studies of P/D and ePD for mesothelioma, median survival ranges from 10 to 57 months.

In one study, 90 pleural mesothelioma patients received multimodal therapy. Their treatment began with systemic chemotherapy, followed by P/D. After surgery, patients able to tolerate it received additional chemotherapy. Chemotherapy consisted of pemetrexed plus cisplatin or carboplatin.

Median overall survival in the study was 57 months. The 1-year and 3-year survival rates were 93% and 65%, respectively.

Studies have also investigated P/D combined with photodynamic therapy and/or radiation. Clinical trials and other medical studies are currently exploring additional P/D-based therapies.

Pleurectomy/Decortication Eligibility

According to experts, P/D can be used successfully for the large majority of pleural mesothelioma cases.

Historically, experts considered pleurectomy/decortication (P/D) as a palliative treatment. Palliative treatments aim to reduce symptoms and improve quality of life. Palliative options do not generally aim to kill or slow the growth of cancer.

Today, P/D still provides palliation. However, experts now recommend P/D as the first choice for surgical treatment of pleural mesothelioma.

Patients diagnosed in an early stage may achieve the best outcomes with P/D treatment. Experts have listed the following as potential qualifying characteristics for P/D:

• Mesothelioma tumors are confined to one side of the body.
• P/D does not pose unreasonable risk to the patient.
• Patient has poor cardiopulmonary function and does not qualify for EPP.
• Patient has early-stage mesothelioma with a minimal number of tumors.
• Patient has extensive mesothelioma that has spread to other essential structures.
• Patient is more advanced in age.

Some doctors may consider certain characteristics as disqualifying for P/D. These characteristics include:

• Biphasic or sarcomatoid cell type
• Tumors with substantial lung invasion

A mesothelioma expert can advise patients on P/D eligibility. They can develop a personalized treatment plan for the patient’s unique case.