Pleurectomy / Decortication or Extrapleural Pneumonectomy for Pleural Mesothelioma?

PD versus EPP Surgeries

Pleurectomy and decortication (P/D) and extrapleural pneumonectomy (EPP) are surgeries for pleural mesothelioma. Both surgeries aim to remove as much tumor tissue as possible. To do this, P/D and EPP remove the tissue lining the outside of the lung (the pleura). P/D surgery does not go on to remove the affected lung. EPP surgery does remove the affected lung.

Doctors have debated the merits of these two surgeries for years, trying to determine which is best. No clear answer has ever surfaced. However, a recent study indicates P/D may be the better option for many mesothelioma patients.

What Is P/D?

Pleurectomy and decortication (P/D) is a surgical treatment for pleural mesothelioma. This surgery removes the lining around the lung (the pleura).

Extended pleurectomy and decortication (EPD) is a slightly more aggressive surgery. In addition to removing the lining outside the lung, EPD also removes the lining around the heart (the pericardium). If the surgeon believes it is necessary, EPD may also remove all or part of the diaphragm.

According to experts, the goal of P/D is macroscopic complete resection (MCR). MCR is a medical term for complete or near-complete removal of all tumor tissue. Simply put, P/D attempts to physically remove as much cancer as possible.

Why Is P/D Considered to Be a Lung-Sparing Treatment?

Pleurectomy and decortication (P/D) and extended pleurectomy and decortication (EPD) are considered lung-sparing treatments. This designation likely stems from P/D and EPD leaving both lungs intact, unlike EPP.

Reported survival for pleural mesothelioma patients undergoing P/D or EPD ranges from 10 to 29 months. Doctors have reported median survival up to 57 months for patients undergoing P/D within a multimodal treatment plan.

Median Survival

The time point at which half of the patients in a study are still alive.

Extrapleural pneumonectomy (EPP) is also a surgical treatment for pleural mesothelioma. Like P/D, EPP removes the pleura, the pericardium and affected portions of the diaphragm. However, EPP goes further than P/D by removing the affected lung as well.

Experts say EPP has a significant impact on postoperative physiology. Losing a lung decreases a person’s cardiovascular function. In some cases, it may also negatively impact quality of life.

Given the nature of the surgery, EPP is considered a higher risk procedure than P/D. However, experts say the elevated risk of EPP comes with a higher chance of complete tumor removal.

Reported survival for pleural mesothelioma patients undergoing EPP ranges from 12 to 22 months. Doctors have reported median survival of up to 39 months for patients treated with EPP combined with other treatments, such as chemotherapy.

Patients should discuss the risks and potential benefits of EPP with an experienced mesothelioma surgeon.

What Are the Differences Between Pleurectomy and Decortication (P/D) and Extrapleural Pneumonectomy (EPP)?

P/D and EPP have a variety of differences that fall into three categories: surgical procedure, eligibility and side effects.

  • Surgical Procedure: Removes only the pleura and potentially the pericardium and diaphragm
  • Eligibility: Most patients with operable tumors are eligible
  • Side Effects: Lower rate of complications and death than EPP
  • Surgical Procedure: Removes the pleura, pericardium, diaphragm and affected lung
  • Eligibility: Patients must have adequate lung function to qualify. Patients with sarcomatoid histology may not be eligible
  • Side Effects: Higher rate of complications and death than P/D; lowered tolerance for post-operative chemotherapy; may be associated with inferior median survival versus P/D

Overall, EPP is a more aggressive, riskier surgical option than P/D. Mesothelioma doctors are still debating which of these surgeries presents the best option for pleural mesothelioma patients. However, a recent study has shed some light on the topic.

2021 Study Says P/D Should Be the Main Surgical Approach in Operable Pleural Mesothelioma

Researchers at The University of Texas MD Anderson Cancer Center have been performing P/D and EPP for at least 20 years. They recently published the results of their procedures from January 2000 to June 2019. During that time period, 282 pleural mesothelioma patients were treated with P/D or EPP.

Patient Characteristics in the MD Anderson Pleurectomy Decortication and Extrapleural Pneumonectomy Study
P/D Patients EPP Patients
# Treated 95 187
Median Age 65 years 61 years
Received Preoperative Chemotherapy 83% 34%
Received Postoperative Radiation 56% 64%

Researchers looked at results for a matched cohort — a smaller set of patients with matching attributes such as age and cancer stage. The matched cohort compared P/D patients to EPP patients with similar characteristics. The matched cohort was created to help eliminate potential flaws in the study results.

In the matched cohort, median survival for P/D was 22 months. Median survival for EPP was 13 months. P/D also appeared superior in terms of perioperative mortality. 11% of EPP patients died during or soon after surgery. None of the P/D patients died during this same time period.

In all their analyses, the study authors did not find “any oncological benefit” of either surgery over the other. The authors noted the goal of pleural mesothelioma surgery should be to remove as much cancer, as safely as possible. Although EPP potentially removes more cancer, it also demonstrated a higher risk of perioperative complications and death. As such, they concluded that future studies should focus on P/D as the main surgical approach.

Past P/D Versus EPP Study Results*

Study Time Period: 1982 to 2012
Study Location: Italy
# Patients: 1365

P/D Median Survival: 20.5 months

EPP Median Survival: 18.8 months

Study Time Period: 2001 to 2013
Study Location: Turkey
# Patients: 76

P/D Median Survival: 27 months

EPP Median Survival: 17 months

Study Time Period: 2004 to 2011
Study Location: United Kingdom
# Patients: 79

P/D Median Survival: 23 months

EPP Median Survival: 12.8 months

Study Time Period: 1998 to 2009
Study Location: Italy
# Patients: 39

P/D Median Survival: 25 months

EPP Median Survival: 20 months

*Some patients in the studies above received EPP, P/D or EPD as part of a multimodal treatment strategy.

Which Is Better: Pleurectomy and Decortication (P/D) or Extrapleural Pneumonectomy (EPP)?

Speaking generally, recent studies support more widespread application of P/D rather than EPP. The American Society of Clinical Oncology recommends P/D or EPD as the first choice over EPP as well. Some experts go further, claiming EPP should be abandoned altogether and “consigned to the surgical history books.”

Still, the ultimate decision should be made on an individual basis. Patients considering either procedure should discuss their options with a top mesothelioma surgeon.