Written By: Camryn Keeble

Pleural Mesothelioma Surgery

Pleural mesothelioma treatment for patients can involve surgery, which is considered the best method to increase survival. There are two surgery options available to treat pleural mesothelioma: extrapleural pneumonectomy (EPP) and pleurectomy with decortication (P/D).

Karen Ritter, RN BSN

Medically Reviewed By

Karen Ritter, RN BSN

Registered Nurse

Karen Ritter, RN BSN

Medically Reviewed By

Karen Ritter, RN BSN

Registered Nurse


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Important Facts About Pleural Mesothelioma Surgery

  • Pleural mesothelioma surgery is not a definitive cure for mesothelioma, but it can remove a large percentage of tumors, which often improves survival for patients.
  • Of the two surgery options for pleural mesothelioma patients, EPP is considered more aggressive as it removes the affected lung. P/D involves the removal of the pleura and potentially the pericardium and part of the diaphragm.
  • Surgery options for pleural mesothelioma remove the pleura and sometimes part of the diaphragm and/or pericardium.

Pleural Mesothelioma Surgery Options

The two primary surgeries for pleural mesothelioma are extrapleural pneumonectomy (EPP) and pleurectomy with decortication (P/D). Extrapleural pneumonectomy is considered more aggressive than pleurectomy with decortication. EPP removes the affected lung, while P/D only removes the pleura. Both surgeries may include the removal of the pericardium and part of the diaphragm, if necessary. 

Mesothelioma surgeons typically have more experience with one of the surgeries, but the decision is most often based on the patient’s circumstances. For instance, some patients are not healthy enough to withstand the stress of surgery, fully recover or survive with just one lung, while others are in an advanced stage of mesothelioma where P/D would not benefit them.

Mesothelioma surgeons prioritize quality of life when determining a treatment plan, so it may not be in the patient’s best interest to remove a lung. In other cases, removing the patient’s lung is the best approach in improving survival. 

Extrapleural Pneumonectomy (EPP) for Pleural Mesothelioma

Extrapleural pneumonectomy (EPP) is an aggressive approach to pleural mesothelioma treatment. EPP is a two-part procedure involving a pneumonectomy (removal of the lung) and the removal of the pleura, which is the thin lining where pleural mesothelioma forms. The pleura covers the surface of the lungs and the inside of the chest wall.

The pneumonectomy segment of EPP involves surgically removing all of the lung along with visceral pleura (the inner cell lining attached to the lung). The “extrapleural” part of the EPP surgery for pleural mesothelioma involves removing the parietal pleura (outer lining of the pleura attached to the chest wall), pericardium (mesothelial lining around the heart), and part of the diaphragm.

Pleurectomy With Decortication (P/D) for Pleural Mesothelioma

Pleurectomy with decortication is the less intense pleural mesothelioma surgery option of the two procedures. It is also a two-part procedure, hence the name “pleurectomy with decortication. Dr. David Sugarbaker, a proponent of P/D, said the surgery was similar to peeling an orange. 

The first part of the surgery is the pleurectomy procedure, which involves removing part of the pleura. Surgeons strip the tumors off the chest wall by peeling the outer pleural lining (parietal pleura) from the chest wall.

The second and final procedure in P/D is decortication. It involves peeling the inner pleural lining (visceral pleura) off the lung, which removes tumors from the surface of the lung. Surgeons also remove other visible tumors in the chest cavity during the decortication procedure. 

Radical Pleurectomy With Decortication

The extended version of P/D is called radical pleurectomy with decortication. This version is more aggressive than standard P/D, which can be referred to as “partial pleurectomy.”

Radical pleurectomy with decortication involves the same procedures as the standard version, but surgeons may also remove other organs or tissues. If the mesothelioma cancer has affected the diaphragm or the pericardium, the surgeon may remove part or all of that tissue.

This approach increases the chances of completely removing most or all of the mesothelioma tumors. Many surgeons prefer the radical P/D surgery to the standard version.

Comparing EPP and P/D

Extrapleural pneumonectomy (EPP) is the original surgical procedure for pleural mesothelioma treatment. It was invented by the late-mesothelioma surgeon Dr. David Sugarbaker. The surgery aims to remove the affected lung as well as the pleura, diaphragm and pericardium. 

For many years, doctors thought the only way to surgically treat pleural mesothelioma was to remove the affected lung, until mesothelioma specialist Dr. Robert Cameron helped pioneer pleurectomy with decortication (P/D).

The two pleural mesothelioma surgeries have sparked debates among mesothelioma surgeons around the world. Many surgeons have a preference for which surgery they’d like to perform and which procedure would be the best treatment options for each patient’s individual needs. However, the decision is ultimately based on what is the best treatment plan for the patient. 

Mesothelioma surgeons have shifted their preferences throughout the decades. From 1995-2012, doctors preferred EPP for mesothelioma:

From 1995-2012 doctors preferred EPP for mesothelioma Chart

PEPP used in 53.4% of surgery cases

P/D used in 46.6% of surgery cases

From 2007-2017, doctors overwhelmingly preferred P/D for pleural mesothelioma:

From 2007-2017 doctors overwhelmingly preferred P/D Chart

P/D used in 81.3% of surgery cases

EPP used in 18.7% of surgery cases

If you have mesothelioma and want to learn more about surgery options, the best plan is to meet with a mesothelioma specialist. You can get a surgery consultation – often virtually – to see if you’re a candidate for either EPP or P/D surgery.

Reach out to our patient advocate team to learn how to meet with a specialist. Email our registered nurse, Karen Ritter, at karen@mesotheliomaguide.com for guidance on meeting with a top surgeon for mesothelioma.

Frequently Asked Questions About Pleural Mesothelioma Surgery

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Can Pleural Mesothelioma Be Removed Through Surgery?

Surgery can remove a large percentage of pleural mesothelioma tumors – sometimes all of them – but patients often have some tumors left behind. Mesothelioma is challenging to treat due to how fast it spreads and grows.

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What Is the Difference Between EPP and P/D?

Extrapleural pneumonectomy (EPP) involves the removal of the affected lung as well as the pleura, part of the diaphragm, and the pericardium (lining of the heart). Pleurectomy with decortication (P/D) does not remove either of the lungs.

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How Does Surgery Help Treat Pleural Mesothelioma?

Surgery can help treat pleural mesothelioma, as it can be one of the most effective treatment options. Pleural mesothelioma surgery can remove the largest percentage of tumors to help extend the patient’s life expectancy.

Sources & Author

  1. Radiation before surgery more than doubles mesothelioma survival: UHN study. University Health Network. Retrieved from: https://www.uhn.ca/corporate/News/PressReleases/Pages/radiation_before_-surgery_doubles_mesothelioma_survival.aspx. Accessed: 04/28/2020.
  2. Initial Analysis of the International Association For the Study of Lung Cancer Mesothelioma Database. Journal of Thoracic Oncology. Retrieved from: https://www.jto.org/article/S1556-0864(15)33132-4/fulltext. Accessed: 02/16/2021.
  3. Extrapleural pneumonectomy (EPP) vs. pleurectomy decortication (P/D). Annals of Translational Medicine. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5497106/. Accessed: 02/16/2021.
  4. Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies. Journal of Thoracic and Cardiovascular Surgery. Retrieved from: https://www.jtcvs.org/article/S0022-5223(04)00396-4/fulltext. Accessed: 02/16/2021.
  5. Effect of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy on Quality of Life in Patients with Peritoneal Mesothelioma. Annals of Surgical Oncology. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/31069554. Accessed: 12/02/19.
  6. Pericardiectomy. Cleveland Clinic. Retrieved from: https://my.clevelandclinic.org/health/treatments/17352-pericardiectomy. Accessed: 02/16/2021.
  7. Complications of Cytoreductive Surgery and HIPEC in the Treatment of Peritoneal Metastases. Indian Journal of Surgical Oncology. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4818615/. Accessed: 02/16/2021.
  8. Morbidity and Mortality Rates Following Cytoreductive Surgery Combined With Hyperthermic Intraperitoneal Chemotherapy Compared With Other High-Risk Surgical Oncology Procedures. JAMA Network. Retrieved from: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2720582. Accessed: 02/16/2021.
  9. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for peritoneal mesothelioma: patient selection and special considerations. Cancer Management and Research. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6511620/. Accessed: 02/16/2021.
  10. The Role of Neoadjuvant Chemotherapy in Patients with Resectable Malignant Pleural Mesothelioma – An Institutional and National Analysis. Journal of National Cancer Institute. Retrieved from: https://www.deepdyve.com/lp/ou-press/the-role-of-neoadjuvant-chemotherapy-in-patients-with-resectable-AMKn0oSv6j. Accessed: 04/01/2020.
  11. Extrapleural Pneumonectomy versus Pleurectomy/Decortication for Malignant Pleural Mesothelioma. Annals of Surgical Oncology. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/33971174/. Accessed: 05/21/2021.
  12. Patients with malignant pleural mesothelioma face barriers to treatment access. Mirage News. Retrieved from: https://www.miragenews.com/patients-with-malignant-pleural-mesothelioma-630474/. Accessed: 09/20/2021.
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About the Writer, Camryn Keeble

Camryn Keeble is the senior content writer and editor for Mesothelioma Guide. She creates informative content to educate mesothelioma patients and their loved ones on news, treatments and more. She also works diligently to raise awareness of the dangers of asbestos exposure and the effects of mesothelioma.