Pleurectomy/Decortication vs Extrapleural Pneumonectomy

What Are Extrapleural Pneumonectomy and Pleurectomy/Decortication?

There is an ongoing debate between extrapleural pneumonectomy surgery and pleurectomy/decortication surgery. The two are often compared for different results: survival; mortality; side effects and complications; surgery recovery time; and quality of life.

First, let’s define just what each mesothelioma surgery entails.

Extrapleural Pneumonectomy (EPP)

Extrapleural pneumonectomy, which is the original surgery developed for treatment of pleural mesothelioma and lung cancer, removing the entire affected lung. Pleural mesothelioma starts in the pleura, which is a thin lining between the lungs and chest wall. The cancer usually begins on only one side of the chest cavity. This lung is usually where tumors spread first.

Extrapleural pneumonectomy, shortened to EPP, removes the entire lung, the pleura (the lining where pleural mesothelioma forms), all or part of the diaphragm, and the lining around the heart.  Removing the affected lung, all visible tumors, and any other diseased tissue is a way of clearing the chest cavity of all tumor growth.

Pleurectomy/Decortication (P/D)

Pleurectomy/decortication, also called pleurectomy with decortication or P/D, does not take out the lung in direct contact to the cancer. P/D focuses on removing the pleura, the lining surrounding the lung. Surgeons strip out this lining in hopes of removing all tumors. Some tumors may have reached the lung but are still attached to the pleura.

Many doctors use a more radical version of P/D – called “extended pleurectomy with decortication” – removing all or part of the diaphragm and the lining around the heart in an attempt to remove all possible tumors.

Overview of the P/D vs EPP Debate

There are a few factors to consider when deciding between pleurectomy/decortication and extrapleural pneumonectomy. Here’s what you should think about when choosing a surgery or surgeon:

• Each surgery is typically better for different stages of mesothelioma. P/D generally is used for earlier stages, while EPP has been better for cancer that has spread more.
• Age and health of the patient can dictate which surgery is used. EPP removes a lung, which can cause a difficult recovery and can impact respiratory function. This may be too aggressive for some patients. 
• Recovery times vary. EPP may require a longer recovery time than P/D due to removing the lung.
• Survival rates and mortality rates for the two surgeries differ. P/D surgery is becoming a first choice for doctors. Many doctors are more comfortable performing P/D surgery, and most studies show better survival rates for P/D than EPP. Each patient should make the decision with their mesothelioma specialist, every case is different.

Why Is There a Debate Between EPP and P/D?

This debate exists primarily because some doctors believe EPP is an antiquated procedure. Supporters of EPP surgery tout the benefits and point to cases where patients lived many years after having the procedure.

A successful EPP surgery, for the right patient, can provide a better chance of removal of all tumors. Dr. David Sugarbaker, who passed away in 2018, created the EPP surgery and believed it to be one of the best ways to treat pleural mesothelioma patients.

“Remove all the visible tumors, and eradicate whatever’s left, at the microscopic level,” he said.

Believers in the P/D surgery say that removing the lung is unnecessary and can do more harm than good, especially for elderly patients, which accounts for most cases of mesothelioma. The average age of pleural mesothelioma patients at the time of diagnosis is 65. So most would be considered older in age.

How Often Is Each Surgery Used?

There has been a dramatic shift in the 21st century towards using P/D surgery more than EPP surgery. Surgeons are prioritizing protecting both lungs and preserving the patient’s quality of life.

From 1995-2012, doctors preferred EPP for mesothelioma:

• EPP 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:

• P/D used in 81.3% of surgery cases
• EPP used in 18.7% of surgery cases

Benefits of EPP Surgery

While EPP surgery is happening less often with each passing year, there are benefits of this surgery over P/D. The main one is a higher chance of removing all tumors during surgery.

EPP might be a better option for younger and healthier patients who can manage and recover from the aggressive aspects of this surgery.. EPP can also give patients in late stages of mesothelioma (stage 3 and stage 4) an option for surgery.

Arguably the best benefit for EPP is this surgery is more likely to remove all mesothelioma cancer cells. The chances of recurrence after EPP surgery are theoretically lower than after P/D surgery. This means EPP can be better at preventing mesothelioma from coming back after treatment ends.

Benefits of P/D Surgery

P/D surgery is less aggressive, preserves both lungs, and typically requires a shorter mesothelioma surgery recovery time. The quality of life is higher for patients after P/D.

P/D has shown to have better survival rates than EPP, and it may be an option for older patients who might have higher health risks. The mortality rates are lower for P/D than they are for EPP surgery. The report was published in Annals of Surgery and details a 5-year survival rate “approaching 25%.” The number is an improvement from past studies.

Studies Comparing EPP and P/D for Mesothelioma

Comparing the survival and mortality rates of EPP surgery and P/D surgery for mesothelioma is common. Doctors and patients need to consider all the risks and benefits for each individual situation to make the best choice. 

An article in the Annals of Translational Medicine compiled data from multiple studies comparing EPP and P/D surgery for mesothelioma. The article is aptly titled “Extrapleural pneumonectomy (EPP) vs. pleurectomy decortication (P/D)” and looks at survival, mortality risk and more.

The article cited four studies where patients received only one of the two surgeries – no chemotherapy, immunotherapy or radiation. In all four studies, the mortality rate for EPP was higher than the mortality for P/D. The two surgeries had comparable average survival times.

The four studies included 1,358 cases of mesothelioma:

• P/D surgery was used in 703 cases, and EPP was used in 655 cases
• The P/D surgery mortality rate was around 3.5% and average survival was around 14.5 months.
• EPP surgery mortality rate was around 7% and the average survival was around 13.5 months.

The article also compared the two surgeries as part of multimodal therapy with other treatments, such as chemotherapy. Nine studies were cited, but some results are worth highlighting.

A study from 2014 included 518 cases, all having EPP surgery with chemotherapy before and after:

• Average survival of 18 months
• 2-year survival rate of 41%
• 5-year survival rate of 14%

A study from 2015 included 102 cases, all having P/D surgery with chemotherapy before and after:

• Average survival of 32 months
• 63% 2-year survival rate
• 23% 5-year survival rate

A study from 2013 included 136 cases, all having EPP surgery with radiation therapy after:

• Average survival of 14.7 months
• 2-year survival rate of 32%

A study from 2016 of 27 cases that had P/D surgery, with chemotherapy before and radiation therapy after:

• Average survival of 24 months
• 2-year survival rate of 59%

‘Adequate Margins’ in Mesothelioma Surgery

The most contentious argument involving the P/D and the EPP is what is known as “adequate margins” of cancer tumor removal. In the field of oncology, doctors and pathologists discuss removal of cancerous tumors and getting adequate margins. The National Cancer Institute defines adequate margins as “the edge or border of the tissue removed in cancer surgery.”

In order to measure the margins, the edge of the tissue surrounding the removed tumor is tested for the presence of any microscopic cancer cells. If there are no cancer cells present, adequate margins have been achieved.

EPP surgery’s theoretical goal is to remove all the cancerous cells possible (adequate margins) to reach a potentially remission situation. However, it is generally accepted by most mesothelioma specialists that complete elimination of mesothelioma cancer cells is not possible with surgery alone. This is why chemotherapy, immunotherapy and radiation are used  before and (usually) after surgery.

The inability to take out all tumors is why many doctors prefer P/D, which is objectively viewed as a better way to maintain the patient’s quality of life.

Which Surgery is Best?

It is not possible to say which surgery is best because  mesothelioma cancer is as unique as each patient. More doctors are turning to P/D surgery as their top surgical choice, but the EPP surgery is still an option for some patients.

There are several institutions using both procedures for pleural mesothelioma treatment. Mesothelioma specialists carefully assess which procedure is more beneficial for their patients based on the individual needs.

Use our free Doctor Match program to find a mesothelioma specialist who can address your specific treatment needs.