Mesothelioma Pleurectomy / Decortication (P/D)

What Is Pleurectomy / Decortication?

Pleurectomy/decortication (P/D) is a two-part surgery. During pleurectomy, the surgeon removes the pleura surrounding the affected lung. During decortication, the surgeon removes visible tumors and scar tissue from the surface of the lung.

P/D treats several pleural conditions, most notably pleural mesothelioma. Pleural mesothelioma is the most common form of the disease and develops in the lining around the lungs. Doctors may use P/D for pleural mesothelioma as part of a multimodal treatment plan.

How Does Pleurectomy / Decortication Treat Mesothelioma?

Pleurectomy/decortication treats mesothelioma by removing the pleura and aiming to remove all visible tumors from the chest cavity. 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 some studies, more complete tumor removal has been linked to longer survival, particularly in epithelioid disease, though this relationship is not fully established.

P/D is often part of a multimodal treatment plan that combines multiple therapies to target remaining cancer cells. Some multimodal treatment plans combine P/D with chemotherapy and/or radiation therapy.

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Types of Pleurectomy / Decortication

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.

ASCO guidelines favor lung-sparing surgery, such as P/D or ePD, over EPP because it carries lower operative and long-term risks. However, ASCO recommends surgical cytoreduction only for highly selected patients with favorable characteristics, including early-stage, epithelioid disease.

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

Surgeons have developed “non-incisional” P/D as an alternative technique. 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 may create an opportunity for cancer cells to break away from tumors. Cutting the visceral pleura may also allow mesothelioma cells to spread within the chest cavity during surgery.

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. Whether this translates into longer survival is not yet established in controlled studies.

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 4 – 6 hours.

The Pleurectomy Procedure

The 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. After the patient receives general anesthesia, the surgical team positions the patient on their side. This provides access to the ribs and chest structures.
3. The surgeon makes an incision between the ribs called a thoracotomy. Depending on the surgical approach, the surgeon may remove a rib to access the pleural space.
4. The surgeon detaches and removes the parietal pleura (the outermost layer of the pleura) from adjacent structures.
5. During extended P/D, the surgeon may also remove cancerous portions of the diaphragm or pericardium (lining of the heart).

The Decortication Procedure

After pleurectomy is complete, the surgeon begins decortication, focusing on the visceral pleura and visible tumor on the surface of the lung. Decortication generally involves the following steps:

1. The surgeon removes the visceral pleura (the layer of the pleura closest to the lungs).
2. The surgeon removes as much visible tumor as possible from the lung while preserving the lung itself. In some cases, tumor that has invaded the lung tissue may require removal of a small portion of the lung.
3. The surgeon also removes lymph nodes to check for cancer spread.
4. If part of the diaphragm was removed during extended P/D, the surgeon will reconstruct that portion of the muscle. This may involve surgical mesh to replace the removed portion of the diaphragm.
5. The surgeon closes all incisions.

Once the procedure is completed, the patient is moved to a recovery area for monitoring.

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 typically inserts a chest tube during P/D. In some cases, a chest tube may be placed or replaced days later if complications develop. Chest tubes help alleviate fluid and air buildup in the chest. Mesothelioma doctors can remove the chest tube once any air leaks have resolved and fluid drainage has decreased to an acceptable level.

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 several 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.

Air leaks can occur after P/D because decortication involves removing tissue from the surface of the lung. Many air leaks resolve while the chest tube remains in place, but persistent leaks may require prolonged chest tube drainage or additional treatment.

A 2018 review by the IASLC Mesothelioma Taskforce examined complication rates across 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%.

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

Benefits and Advantages of Pleurectomy / Decortication

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

• Lower short-term mortality: A meta-analysis of 24 studies found short-term mortality of 1.7% after P/D compared with 4.5% after EPP. Short-term mortality refers to death within 30 days of surgery.
• Lower operative risk: P/D preserves the affected lung and carries lower operative risk than EPP.
• Quality of life: Some studies suggest patients may have better quality of life after P/D than EPP, though evidence is limited and results have been mixed.
• More treatment options: Preserving both lungs may help patients remain eligible for additional treatment after surgery or if the cancer returns.
• Broader eligibility than EPP: More patients who are candidates for surgery may be eligible for P/D than EPP.

These factors are why P/D is generally preferred over EPP when surgery is used, though current guidelines restrict surgery itself to carefully selected, early-stage patients with epithelioid disease. 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.

P/D and EPP have both similarities and important differences. A 2023 National Cancer Database study found that 27.6% of patients diagnosed with pleural mesothelioma from 2004 to 2020 underwent surgery. For patients who undergo surgery, there are two main surgical options: P/D and extrapleural pneumonectomy (EPP).

The two procedures share many common steps. In fact, EPP can be explained as extended P/D with removal of the affected lung. Despite these similarities, the two procedures are quite different. Recent studies indicate EPP has a higher risk of complications and short-term mortality than P/D.

Studies generally show lower short-term mortality with P/D than EPP, while evidence comparing long-term survival comes from retrospective studies and remains less certain. Current guidelines favor lung-sparing P/D over EPP when surgery is appropriate.

Pleurectomy / Decortication Prognosis and Survival

Mesothelioma prognosis and survival after pleurectomy/decortication depend on several factors. Mesothelioma stage, treatment approach and patient characteristics can all affect survival.

In one study, 90 pleural mesothelioma patients with epithelioid disease underwent extended P/D combined with intraoperative photodynamic therapy (PDT), a light-based treatment aimed at residual microscopic disease; 92% also received pemetrexed-based chemotherapy.

Median overall survival in the 73 patients analyzed was 3 years, with disease-free survival of 1.2 years. In the subset of 19 patients with no lymph node involvement, median overall survival reached 7.3 years.

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.

A 2024 randomized trial (MARS 2) tested whether adding extended P/D to chemotherapy helped patients with resectable pleural mesothelioma live longer than chemotherapy alone. The surgery group had shorter survival: patients who had surgery lived a median of 19.3 months, compared with 24.8 months for patients who received chemotherapy without surgery. The surgery group also had more serious complications. Current National Comprehensive Cancer Network guidelines note that the benefit of surgery in pleural mesothelioma is unclear outside carefully selected, early-stage, node-negative, epithelioid cases.

Pleurectomy / Decortication Eligibility

Current guidelines recommend considering P/D only for carefully selected patients with early-stage, node-negative, epithelioid pleural mesothelioma who meet specific heart and lung function criteria.

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. For carefully selected patients, P/D may also be used as part of a multimodal treatment plan.

Patients considered for surgery should have favorable characteristics, including:

• Early-stage, node-negative disease
• Epithelioid cell type
• No cancer spread outside the chest
• Adequate heart and lung function for surgery
• Ability to receive multimodal treatment

Certain characteristics may rule out P/D or other major mesothelioma surgeries, such as extrapleural pneumonectomy (EPP). These include:

• Sarcomatoid cell type
• Cancer that has spread outside the chest
• Inadequate heart or lung function for surgery

Mesothelioma develops in three main cell types: epithelioid, sarcomatoid and biphasic. Biphasic mesothelioma contains both epithelioid and sarcomatoid cells. Cell type is one of several factors doctors consider when determining whether P/D is appropriate.

A mesothelioma specialist can determine whether P/D is appropriate and recommend an individualized treatment plan.