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Mesothelioma Pleurectomy / Decortication

A pleurectomy and decortication (P/D) is a surgical procedure used to treat malignant pleural mesothelioma. The surgery involves the removal of cancerous tissue without complete removal of the infected lung.

A pleurectomy and decortication (P/D) is a surgical procedure performed on early-stage pleural mesothelioma patients. Often called “lung-sparing surgery,” P/D is a less radical procedure than extrapleural pneumonectomy (EPP), another common surgical treatment for pleural mesothelioma. Studies have shown that P/D typically results in fewer risks than EPP, while still extending patient life expectancies. The surgical procedure is often used in combination with other treatment modalities, like chemotherapy and radiation therapy, as part of a multimodal mesothelioma treatment plan.

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How Pleurectomy / Decortication Treats Mesothelioma

Studies have estimated that more than 20% of all pleural mesothelioma patients undergo surgery, typically an extrapleural pneumonectomy or a pleurectomy/decortication. P/D is used to treat early-stage pleural mesothelioma, specifically if the cancer has yet to metastasize and is localized on one side of the body. When applied in this way, doctors aim to remove as much of the cancerous tissue as possible. In some cases, pleural mesothelioma patients with advanced disease may also receive the surgery for palliative purposes to control fluid buildup and improve breathing.

Like an EPP, a pleurectomy/decortication is applied with the goal of macroscopic resection (MCR) of pleural mesothelioma. MCR removes all signs of cancer that are visible to the naked eye. Compared to an EPP, a P/D is the less radical of the two surgical options, and as such, there is less risk of mortality following the procedure. However, there is a greater chance of microscopic disease (cancer invisible to the naked eye but detectable by microscope) following completion of P/D than with EPP. Currently, there are no viable microscopic resection options for pleural mesothelioma patients.

A pleurectomy and decortication is a two-part procedure that commonly begins with a thoracotomy, an incision between the ribs. Following the thoracotomy, surgeons will begin the pleurectomy and then the decortication. When performed for palliative purposes, the pleurectomy may be administered on its own. The surgery takes many hours to complete and patients may be under general anesthesia for four to six hours.

  1. Thoracotomy:A thoracotomy involves a long incision into the chest between the ribs for surgical access to the lungs. The incision may be performed on the right or left side depending on which lung is being operated on.

  2. Pleurectomy:Surgical procedure to remove the pleura, or lung linings.

  3. Decortication:Surgical removal of all visible tumors from within the chest cavity.

Pleurectomy Procedure

Once the thoracotomy is complete and the mesothelioma surgeons have gained access to the diseased portion of the lung, the lung lining may be removed. The procedure begins between the endothoracic fascia (connective tissue near the ribs) and the parietal pleura, which is the outer membrane of the pleural cavity. The ribs are spread slowly to prevent breakage and the pleura is removed from the chest wall. Again, this procedure may be used alone for palliative purposes to alleviate pain caused by pleural effusions (fluid buildup within the lungs).

Decortication Procedure

During decortication, the lung is deflated to reduce blood loss while completing the procedure. However, loss of blood is typical, and patients often receive blood transfusions throughout the decortication. The surgeons then begin resecting all visible tumors from within the visceral pleura (outer layer of the lung). Cancer-impacted lymph nodes may also be removed during decortication.

Eligibility for Mesothelioma Pleurectomy/decortication

To safely undergo P/D, pleural mesothelioma patients must have early-stage disease with adequate cardiopulmonary function. Patients are not excluded from the procedure based on age alone, with studies showing P/D has been well-tolerated by those 70 years old and older. A surgical option suited to this demographic is crucial for mesothelioma cancer, as the disease often impacts seniors due to its long latency period.

Regardless of patient age, it is up to the discretion of a patient’s medical team to determine if their overall health is good enough to withstand the surgery. Doctors use non-invasive pulmonary function testing to measure a patient’s lung volume, capacity and ability to diffuse carbon monoxide. Other imaging scans, such as an MRI, CT or PET scan, may be used prior to P/D to ensure that a surgical approach is the best option for the patient.

Once the preliminary testing assures doctors that the patient is a candidate for surgical procedures, they next consider histology, or cell type. Biopsies are used to determine a mesothelioma patient’s specific histology, which can then aid mesothelioma doctors in best treating their cancer. Most commonly, a P/D procedure is completed on patients presenting with epithelioid mesothelioma. This type of pleural mesothelioma has been found to best respond to surgical treatment. However, some mesothelioma cancer centers may perform pleurectomy and decortication on patients with biphasic histology, or those presenting with both epithelioid and sarcomatoid cells. Most mesothelioma specialists agree that patient’s with purely sarcomatoid pleural mesothelioma are not viable candidates for the procedure because it is the most aggressive cell type and does not respond well to treatment.

One study found that a patient's mesothelioma histology or cell type was a strong indicator of overall survival time following P/D. Researchers found those with purely epithelioid pleural mesothelioma had the most favorable survival time, with patients experiencing a median overall survival of about 20 months. Patients with biphasic mesothelioma and between 51 – 99% epithelioid histology had a median overall survival of 11.8 months, while biphasic mesothelioma patients with less than 50% epithelioid cells had a median survival of just 6.62 months. In general, pleural mesothelioma patients survive for six months to one year after diagnosis.

Side Effects and Risks of Pleurectomy / Decortication

While commonly referred to as a less radical surgery for patients, a pleurectomy/decortication is still a serious surgery that requires extensive recovery. Patients often require hospitalization for at least one week following the procedure. However, even after discharge from the hospital, side effects may emerge. Side effects, from mild to more severe, may arise at any time during patient recovery.

Common Side Effects of Pleurectomy/decortication
  • Air leaks from within the lung
  • Bleeding
  • Blood clots
  • Changes in heart rhythm
  • Chest pain
  • Chest tightness
  • Cough
  • Dyspnea (breathing difficulty)
  • Fluid in the chest (peritoneal effusion)
  • Pneumonia
  • Wound infections

A patient's activity may be limited for one to two months while recuperating. However, for some patients the surgery may lead to a better quality of life, making the risks worthwhile. According to one retrospective analysis, patients who’ve undergone P/D for pleural mesothelioma had a significantly better overall quality of life when compared to those treated with EPP. Analysis of 100 patients who were treated with P/D found that:

After EPP, patients were found to have reduced pulmonary function and increased breathing difficulties when compared to those that received a pleurectomy and decortication. Lung capacity specifically was reduced in those who received EPP’s, from 77.7% preoperatively to just 55.3% after the procedure.

Having two possible surgical treatment options available to patients enables doctors to select the approach best suited for their specific case. Whether treating malignant mesothelioma with surgery alone or with a multimodal approach, patients should be aware of risks associated with all potential treatment options before undergoing any treatment.

Author: Linda Molinari

Editor in Chief, Mesothelioma Cancer Alliance

Linda Molinari

Reviewer: Annette Charlevois

Patient Support Coordinator

Annette Charlevois
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Sources

American Cancer Society. Surgery for Malignant Mesothelioma.

Baylor College of Medicine. Pleurectomy and Decortication. Procedures.

Friedberg JS. The state of the art in the technical performance of lung-sparing operations for malignant pleural mesothelioma. Seminars in Thoracic and Cardiovascular Surgery. Summer 2013;25(2):125-43. doi: 10.1053/j.semtcvs.2013.07.002

Johns Hopkins Medicine. Pulmonary Function Tests. Health Library.

Ploenes T, Osei-Agyemang T, et al. Changes in lung function after surgery for mesothelioma. Asian Cardiovascular & Thoracic Annals. February 2013;21(1):48-55. doi: 10.1177/0218492312454017

Rusch V. Pleurectomy and Decortication: How I Teach It. The Annals of Thoracic Surgery. May 2017;103(5):1374–1377. doi: 10.1016/j.athoracsur.2017.02.042

Schwartz R, Watson A, et al. The impact of surgical approach on quality of life for pleural malignant mesothelioma. Annals of Translational Medicine. June 2017;5(11):230. doi: 10.21037/atm.2017.03.41

Vigneswaran WT, Kircheva DY, et al. Amount of Epithelioid Differentiation Is a Predictor of Survival in Malignant Pleural Mesothelioma. The Annals of Thoracic Surgery. March 2017;103(3):962-966. doi: 10.1016/j.athoracsur.2016.08.063

Vlahu T, Vigneswaran W. Pleurectomy and decortication. Annals of Translational Medicine. June 2017; 5(11): 246. doi: 10.21037/atm.2017.04.03

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