Mesothelioma patients have just a few universally approved treatment options. Not long ago, they had even fewer.

Extrapleural pneumonectomy was the lone surgical option for years. Peritoneal mesothelioma patients had a more invasive and prolonged form of cytoreduction surgery than they do today.

What changed? Many aspects did, but the emergence of “hot chemotherapy” might be the most notable one.

The use of hyperthermic chemotherapy has increased the effectiveness of peritoneal mesothelioma surgery — and could for pleural mesothelioma operations. Pumping the liquid chemotherapy drugs directly into the abdomen or thorax is also phasing out the necessity of more encroaching procedures.


The Use of Extrapleural Pneumonectomy for Pleural Mesothelioma

Extrapleural pneumonectomy (EPP) is the most invasive mesothelioma surgery and was one of the first procedures available to pleural mesothelioma patients. The first cited use of EPP, in an article published in the Annals of Thoracic Surgery, was in 1958. For the next half-century, this procedure was one of the most often-used treatment approaches for patients with early stage pleural mesothelioma.

The procedure involves removing numerous areas of the body, along with an organ:

  • The protective membrane between the chest and lung cavity, which is known as pleura and where pleural mesothelioma forms
  • Part of the pericardium, a protective lining around the heart
  • Part of the diaphragm
  • The lung nearest to where mesothelioma formed

Removing an entire lung is an unappealing aspect of EPP. However, pleural mesothelioma patients have a new option.

extrapleural pneumonectomy for pleural mesothelioma


The Rise of Pleurectomy With Decortication for Pleural Mesothelioma

In the mid-1990s, specialists at the University of California Los Angeles Medical Center began revamping a new surgery for pleural mesothelioma. According to the Pacific Heart, Lung, & Blood Institute website, pleurectomy with decortication (P/D) would spare the lung and focus solely on the pleura.

Pleurectomy involves the removal of part of the pleura. The decortication portion of the procedure for mesothelioma usually involves removing the tissue that surrounds the lung and diaphragm.

The surgery gave people an alternative for removing their tumors and has split many people within the mesothelioma treatment industry. P/D is considered safer than extrapleural pneumonectomy — because the lung isn’t removed — but the surgery is only for early stage patients. If the cancer hasn’t spread to the nearby lung — or only just started affecting the organ — then patients theoretically could keep their lung and remove the tumors.

If a patient’s lung is overrun with mesothelioma tumors, then EPP is likely the only option.

Or, should we say, it was the only option.

pleurectomy with decortication for pleural mesothelioma


How Heated Chemotherapy Works for Peritoneal Mesothelioma

Peritoneal mesothelioma is a form of the disease that develops in the peritoneum, which lines the abdominal cavity. The primary operation for peritoneal mesothelioma is cytoreductive surgery, which involves the removal of part or all of the peritoneum to evict all mesothelioma tumors from the area.

However, the microscopic tumors may metastasize into the abdominal cavity and affect organs like the intestine, gallbladder, kidneys and pancreas. So would surgeons have to remove these organs, thus conducting a more invasive surgery than preferred? If not, how could surgeons improve their patient’s post-surgery prognosis and remove as many tumors as possible? Peritoneal mesothelioma specialists faced these questions.

The answer to them was — and still is — heated chemotherapy.

According to the Annals of Translational Medicine, heated intraperitoneal chemotherapy (HIPEC) joined cytoreductive surgery in the mid-1980s as a front-line treatment for peritoneal mesothelioma. Rather than the chemotherapy drugs delivered intravenously into the patient’s blood, they are administered in liquid form directly into the abdominal cavity.

Numerous studies have reported excellent results from using HIPEC with cytoreductive surgery. Patients who undergo this procedure have a median survival of around 60 months, and the five-year survival rate for them is close to 50%. By comparison, patients who simply undergo chemotherapy, radiation or a less-invasive surgery have a much shorter life expectancy.

Now, more than three decades later, pleural mesothelioma specialists are implementing heated chemotherapy to their surgical practices.

cytoreduction and HIPEC for peritoneal mesothelioma


Combining Heated Chemotherapy and Pleurectomy With Decortication

The Journal of Thoracic Disease published the results of a study that appeared on the U.S. National Library of Medicine website in May 2019. The study analyzed 71 people who had localized pleural mesothelioma — meaning a Stage 1 disease — and underwent surgery between 2009 and 2013.

The patients underwent P/D, the less-invasive option for treating pleural mesothelioma. At the end of the operation, they received hyperthermic intrathoracic chemoperfusion, which is heated chemotherapy delivered into the thorax. This region of the body includes the lung cavity, the since-removed pleura and the diaphragm. The surgeons used cisplatin and doxorubicin as the chemotherapy drugs.

Despite the cancer’s localized status, tumors are microscopic and could spread to other areas not removed during surgery. The chemotherapy can attack the remnant cells, preventing a recurrence of the cancer.

Patients with the epithelioid cell type survived for a median amount of 17 months following surgery, which is promising news. The average survival time for pleural mesothelioma patients is between a few months and two years, mostly depending on the stage of their disease at the time of diagnosis.

People who had a complete macroscopic resection — meaning the surgeons also removed the diaphragm and/or pericardium — had even better outcomes. Their median survival time following surgery was around 28 months, more than double the median of 13 months for patients who did not undergo complete resection.

The researchers felt the study was a success, saying heated intrathoracic chemotherapy combined with P/D is “a safe therapeutic option” for people with epithelioid pleural mesothelioma.

heated chemotherapy in the chest cavity


What Does This Mean for EPP’s Future?

What if pairing P/D with heated chemotherapy could help patients with Stage 2 or Stage 3 pleural mesothelioma?

EPP remains most useful when specialists know the patient’s mesothelioma has spread to the nearby lung. This level of the disease is not Stage 1 or “localized.” But could hyperthermic chemotherapy delivered directly into the thorax attack tumors that have spread to the lungs, diaphragm and other organs?

In essence, would heated chemotherapy lessen the necessity for EPP in treating pleural mesothelioma?

From a surface-level standpoint, this thought process makes sense. P/D removes the pleura and other infected tissue. The chemotherapy drugs attack the cells that spread to other thoracic areas.

Heated chemo is still relatively new, though, and specialists continue to experiment with and perfect its application. At least for the next few years, EPP remains a featured surgical option for pleural mesothelioma patients. If tumors have reached the nearby lung, there’s no quicker way to removing the cancer than merely taking out that organ and moving forward.

If you have mesothelioma and want to learn your treatment options or are considering which route to take, contact our patient advocate team. Karen Ritter, a registered nurse, is the top medical resource for people afflicted with this cancer. She can connect you with the top mesothelioma specialists in the country and provide extra insight into how treatment works. Email her at for additional information on surgery, chemotherapy and more.

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    Sources & Author

  1. Pleurectomy/decortication and hyperthermic intrathoracic chemoperfusion using cisplatin and doxorubicin for malignant pleural mesothelioma. Journal of Thoracic Disease. Retrieved from: Accessed: 07/18/19.
  2. Extrapleural Pneumonectomy for Diffuse, Malignant Mesothelioma. Annals of Thoracic Surgery. Retrieved from: Accessed: 07/18/19.
  3. Extrapleural Pneumonectomy. University of California San Francisco Department of Surgery. Retrieved from: Accessed: 07/18/19.
  4. Chemoperfusion. Baylor College of Medicine. Retrieved from: Accessed: 07/18/19.
  5. Debunking the Myths About Mesothelioma Procedure Pleurectomy and Decortication. Pacific Heart, Lung, & Blood Institute. Retrieved from: Accessed: 07/22/19.
  6. Malignant peritoneal mesothelioma: a review. Annals of Translational Medicine. Retrieved from: Accessed: 07/26/19.
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About the Writer, Devin Golden

Devin Golden is the content writer for Mesothelioma Guide. He produces mesothelioma-related content on various mediums, including the Mesothelioma Guide website and social media channels. Devin's objective is to translate complex information regarding mesothelioma into informative, easily absorbable content to help patients and their loved ones.