Written By: Karen Ritter, RN BSN
Mesothelioma pleurectomy/decortication (P/D) is a type of surgery for mesothelioma to remove tumors on and near the lungs. This procedure is available to people with pleural mesothelioma if tumors have not spread into the lung tissue or beyond the chest cavity.
Medically reviewed for accuracy by
Dr. Hassan Khalil
Mesothelioma Thoracic Surgeon
JUMP TO A TOPIC
Mesothelioma pleurectomy/decortication (P/D) is a type of surgery used to remove mesothelioma tumors around the patient’s lung. This surgery is used to treat pleural mesothelioma, which is the most common type of mesothelioma.
Pleural mesothelioma is a cancer that forms in the lining around the lungs (the pleura). This lining is a buffer of thin tissue layers and fluid that allows the lungs to expand safely against the chest wall.
Pleurectomy/decortication treats mesothelioma by removing the pleura and any tumors in this area. The goal is to remove all tumors and other cancerous cells from the patient’s body.
P/D surgery is a type of mesothelioma treatment that “spares” both of the patient’s lungs to help preserve their quality of life. Removing the pleura with P/D surgery can eliminate tumors in the pleura and on the surface of the lung.
Mesothelioma tumors can spread from the pleura to the lung. Early detection of the cancer – before tumors have covered the lung – can improve eligibility for pleurectomy/decortication surgery.
Pleurectomy is a surgical procedure to remove the pleura, which is the lining of the lungs. Doctors remove the pleural lining from the chest wall, which is called the “parietal pleura.”
Decortication is a surgical procedure to remove the inner layer of the pleura, which is on the surface of the lungs. This tissue layer is called the “visceral pleura.”
The benefits of pleurectomy/decortication for mesothelioma include complete elimination of the disease and better quality of life for the patient.
Doctors perform P/D in hopes of improving the patient’s survival. They also perform P/D to spare both of the patient’s lungs, which can prevent breathing issues.
The quality of life after pleurectomy/decortication surgery is usually higher than other surgery options for patients.
Pleurectomy/decortication surgery is one of two operations used to treat pleural mesothelioma. The other surgery is called extrapleural pneumonectomy (EPP). EPP is more aggressive because doctors remove the entire lung affected by mesothelioma.
Removing a lung can impact a patient’s quality of life, as this leaves one lung responsible for all breathing functions. This can result in shortness of breath and limited exercise tolerance.
Pleurectomy/decortication spares the affected lung and can preserve a better quality of life. People are more likely to recover fully and have less impact on their breathing following P/D surgery.
“What we’re finding is that preserving the lung is the most important thing.”
Mount Sinai Medical Center
Researchers in Japan analyzed the impact of P/D surgery on quality of life compared to EPP surgery. They found that patients had less body pain after the operation compared to EPP surgery and also regained their social function and energy level.
In another study comparing P/D and EPP, patients had better physical and social function following P/D surgery. Pain and cough were similar after the two surgeries.
Mesothelioma survivor Gary Maxwell underwent P/D surgery, and while he has some mild lingering side effects from the operation, he is “alive and enjoying life” thanks to the treatment.
“Now, life is wonderful. It’s like somebody takes the blinders off of you, and you’re able to say, ‘Wow.’ Things stand out to you that you weren’t able to see before.”
Pleural Mesothelioma Survivor
Pleurectomy/decortication helps prevent fluid buildup by removing the pleura, which is where fluid buildup occurs.
As mesothelioma tumors grow and multiply in the pleural lining, the body loses the normal ability to drain excess fluid from the pleural space, which is the gap between the lungs and the chest wall. This leads to a buildup of fluid that presses against the chest wall and lungs, causing discomfort and difficulty breathing. This common mesothelioma symptom is called pleural effusion.
Pleurectomy/decortication surgery eliminates the development of pleural effusions.
The mesothelioma prognosis for patients after pleurectomy/decortication surgery depends on several factors:
These factors lead to varying survival times in studies of P/D surgery.
Mesothelioma survival rates can be promising for patients after P/D surgery.
Mesothelioma develops as multiple small tumors rather than one bulky mass. This makes removing the entire disease difficult, as some tiny tumors may not be found during surgery. However, P/D surgery can eliminate the majority of tumors and improve life expectancy.
A study recently published in the Annals of Thoracic Surgery – led by Dr. Anne Tsao, a mesothelioma specialist at MD Anderson Cancer Center in Houston, TX – showed a median survival of 22 months for mesothelioma patients treated with P/D surgery.
Another study, published in the European Journal of Cardiothoracic Surgery, reported a 3-year survival rate of 40% for people who had P/D surgery.
A third study, published in Interdisciplinary Cardiovascular and Thoracic Surgery, showed P/D surgery led to a median survival of 3 years. For patients with stage 1 mesothelioma, pleurectomy/decortication led to a median survival of more than 6 years.
Studies show that P/D surgery combined with other therapies can lead to lengthy survival times. Other mesothelioma treatments like chemotherapy, immunotherapy and radiation can be given before or after P/D surgery.
Below are survival statistics of combining P/D surgery with other treatments to help extend life expectancy:
Chemotherapy, P/D surgery, and then radiation
23.7 months median survival and 59% 2-year survival rate
Chemotherapy, P/D surgery, and then chemotherapy again
32 months median survival and 63% 2-year survival rate
P/D surgery, then chemotherapy and radiation
32 months median survival and 25% 5-year survival rate
Gary Maxwell
Pleural Mesothelioma Survivor
MESOTHELIOMA SURVIVORS FOLLOWING P/D SURGERY
There have been many mesothelioma survivors – people who have lived for 10 or more years cancer-free – thanks to P/D surgery. Gary Maxwell, who was diagnosed with mesothelioma in 2014, is one such story.
Gary is thankful for the doctors and nurses who guided him through the surgery. He recommends the treatment to anyone eligible for surgery.
The steps of pleurectomy/decortication might be different with each doctor and cancer center. However, all P/D surgeries begin with anesthesia. The anesthesiologist will place a breathing tube to ensure optimal oxygenation during surgery.
P/D surgery can take up to 6-12 hours.
1
The patient is carefully placed on their side so the surgeon has easy access to the side of the chest.
2
An incision is made that starts on the patient’s back and extends around to the front under the pectoral muscle. The sixth rib is usually removed to allow space for the surgeon to enter the chest cavity.
3
Parietal pleurectomy - The parietal (outer) pleura is removed from the chest wall.
4
The doctor will take out any tumors and diseased tissue along the chest wall, diaphragm and pericardium.
5
Visceral pleurectomy - The visceral (inner) pleura is removed from the surface of the lung. This is a time-consuming process since doctors want to protect the lung. Visceral pleurectomy usually happens during the decortication part of surgery.
1
Surgeons remove all visible tumors and diseased tissue.
2
The surgeon will remove necessary lymph nodes within the chest cavity to determine if mesothelioma has spread.
3
Doctors may opt to use intraoperative heated chemotherapy or intraoperative betadine. This therapy is circulated in the chest cavity and then drained before the end of surgery.
4
Reconstruction - The surgeons may use Gore-Tex or other mesh products to perform reconstruction of the diaphragm and pericardium. Sutures are used to close the incision in the chest.
5
Cavity examination and lung repair - Doctors will often insert chest tubes to ensure the lung re-expands normally. Chest tubes can also ensure proper fluid drainage from the space around the lung.
People diagnosed with pleural mesothelioma might be eligible for pleurectomy/decortication surgery. Eligibility depends on several factors, including how far tumors have spread.
Mesothelioma specialists are the best at evaluating patients to determine if surgery is safe and beneficial. They have the most experience performing surgery for mesothelioma and should be trusted to make the decision regarding surgical options.
Stage of mesothelioma – Patients with more advanced stages are less likely to be eligible due to the spread of tumors.
Patient’s health – Doctors will evaluate the patient’s health to determine if they will recover well and have a good quality of life following surgery.
Mesothelioma cell type – The epithelioid mesothelioma cell type is the easiest to treat with surgery, while sarcomatoid mesothelioma is the toughest.
A surgical consultation is a meeting between a surgeon and potential patient to discuss surgical options. The consultation can include an overview of different surgeries for the patient’s condition, the doctor’s treatment recommendations, and potential risks. Surgical consultations are an important first step in determining eligibility for surgery and comfort level with the doctor.
Mesothelioma Guide patient advocates will help you contact mesothelioma specialists for your specific needs. Reach out to our registered nurse, Karen Ritter, through the Mesothelioma Guide free contact form to receive personalized assistance and resources.
There are two types of pleurectomy/decortication for mesothelioma: standard P/D; and extended P/D.
Standard pleurectomy/decortication is a type of P/D surgery that primarily removes the pleura. Doctors usually remove the pleura by making small incisions to remove pieces of the tissue lining. The goal of this surgery is to remove all tumors in the pleura and any other visible mesothelioma tumors.
Extended pleurectomy/decortication for mesothelioma is a type of P/D surgery that removes the pleura, part or all of the diaphragm, and part or all of the pericardium (lining around the heart). It is a more aggressive surgery than standard pleurectomy/decortication but can lead to a greater amount of tumors removed from the patient’s body.
A rarely used technique called a non-incisional pleurectomy/decortication removes the pleura without making incisions into the pleural lining. The entire pleura is removed in one piece. The name can be misleading, as patients may think doctors can perform the surgery without an incision into their chest. This is incorrect. There is always an incision into the chest to give doctors access to the chest cavity.
Who you select for P/D surgery is important, which is why you should choose a mesothelioma specialist. Mesothelioma Guide has a database of doctors who are experienced in performing pleurectomy/decortication for mesothelioma with high success rates.
“I prefer to spare the lung if possible,” says Dr. Bograd (Swedish Cancer Institute), who was awarded the 2023 Thoracic Surgery Top Doctor award. “I think patients are more able to get further treatments after P/D surgery.”
Our patient advocate team can help you contact one of these top mesothelioma doctors or cancer centers for surgery. Find an experienced mesothelioma surgeon using our free Doctor Match program.
Patients can prepare for mesothelioma pleurectomy/decortication surgery by educating themselves about the procedure. Patients who are empowered with information – and who feel comfortable asking their doctor questions – are best prepared for major mesothelioma surgery.
QUESTIONS TO ASK YOUR DOCTOR BEFORE SURGERY
Before pleurectomy/decortication surgery, patients may need the following tests:
Recovery after P/D surgery for mesothelioma usually lasts 1-2 months:
Patients spend 7-10 days in the hospital after surgery.
Outpatient recovery takes 2-6 weeks.
Patients will have a follow-up appointment approximately 1-2 weeks after being discharged from the hospital. Subsequent postoperative appointments range from every 3-4 weeks to every 3-6 months depending on the patient.
During follow-up appointments the doctor will:
1
Following P/D surgery, most patients go to the intensive care unit (ICU). They will be on oxygen and may have a breathing tube. They may also have a chest tube to ensure the lung remains fully inflated and to help drain excess fluid around the lung.
2
Patients are encouraged to start walking as soon a possible. This is part of the physical therapy process following surgery. Walking helps with circulation, improves breathing, and promotes healing.
3
Doctors also recommend breathing and coughing exercises, which can help:
1
After discharge from the hospital, patients begin their outpatient recovery at home or in a rehabilitation facility.
2
Patients are encouraged to rest and heal.
3
Patients continue physical therapy (like walking) to regain strength, mobility and stamina.
4
Breathing exercises help improve lung capacity and clear mucus.
The potential side effects of pleurectomy/decortication surgery include:
Pain
Bleeding
Difficulty
breathing
Air leaks
in the lungs
Mucus buildup
in the lungs
More serious side effects may lead to intraoperative or postoperative death. However, death during or immediately after P/D surgery is rare. It’s lower when the surgery is performed by a mesothelioma specialist at a cancer center of excellence.
Using data from multiple studies, the mortality rate for pleurectomy/
Mesothelioma recurrence following pleurectomy/decortication surgery is possible. Tumors could return after the operation. Mesothelioma is an aggressive cancer and has a high rate of recurrence due to how the cancer grows and spreads.
Doctors at the top cancer centers have the best success rates with P/D surgery. They provide the best chance of eliminating all tumors to prevent recurrence for patients.
Approximately one-third of people in the United States diagnosed with mesothelioma are military veterans. The high rates of mesothelioma among veterans led to the creation of mesothelioma treatment programs at select VA medical centers.
Veterans with mesothelioma can receive P/D surgery through the VA health care system if they’re enrolled.
Two VA medical centers have mesothelioma specialists who see veterans at the centers and can perform surgery:
Contact the Mesothelioma Guide veterans advocates team for help scheduling an appointment.
Pleurectomy/decortication (P/D) surgery is a type of treatment for mesothelioma. Mesothelioma is a rare cancer that often forms in the lining of the lungs (called the pleura). P/D is called a “lung-sparing” procedure since neither lung is removed. The surgeon removes the patient’s pleura – usually by stripping it off the chest wall and the surface of the lung – along with any visible cancerous tissue in the chest cavity. Doctors may also take out part of the diaphragm and the lining around the heart.
Pleurectomy/decortication surgery usually lasts 6-12 hours. The length of the procedure varies based on the extent of the patient’s mesothelioma. If their cancer is in early stages – meaning it is contained to the pleura – then the procedure can be shorter. If the cancer has spread and there is a lot of diseased tissue to remove, then it can last longer.
Eligibility for pleurectomy/decortication surgery depends on several factors. They include the patient’s overall health and lung function, the stage of disease, and the mesothelioma cell type. Patients will go through screening tests to determine their health status and ability to recover from an aggressive surgery for mesothelioma.
The average mesothelioma survival for people who have pleurectomy/decortication surgery is 2-3 years. The 5-year survival rate following P/D surgery is approximately 25%. Going to a top cancer center with mesothelioma specialists improves the survival rate. Numerous studies have found that cancer patients have longer survival when they go to cancer centers tied to academic universities.
The risks of pleurectomy/decortication surgery include pain, difficulty breathing, mucus buildup and air leaks in the lungs. More serious risks include blood clots, infections, pneumonia, cardiac or respiratory failure, and a collapsed lung.
The recovery time for patients following pleurectomy/decortication surgery is 1-2 months. The specific recovery time varies for each patient. Most people spend 7-10 days in the hospital following P/D surgery. This recovery process includes walking, breathing exercises and regaining strength. Outpatient recovery, which takes place at the patient’s home or a rehabilitation facility, lasts 2-6 weeks.
People with mesothelioma are recommended to visit a cancer center for pleurectomy/decortication surgery. Mesothelioma cancer centers of excellence have experienced, trained specialists with a track record of success performing this surgery. Some of the top mesothelioma cancer centers where patients go for P/D surgery are:
Sources & Author
