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Written by Karen Ritter, RN BSN

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Mesothelioma Pleurectomy With Decortication (P/D)

Mesothelioma pleurectomy with decortication (P/D) is a surgical procedure for patients diagnosed with pleural mesothelioma. The surgery is performed on one side of the chest, removing the pleura but leaving both lungs intact. It's called a lung‑preserving mesothelioma surgery.

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Important Facts About Mesothelioma Pleurectomy With Decortication

  • P/D for mesothelioma is a two‑part procedure: pleurectomy and decortication. It removes the lining around the lungs.
  • An “extended” or “radical” version of P/D removes the diaphragm and pericardium (lining around the heart), with or without mesh reconstruction.
  • Doctors may combine P/D with chemotherapy, radiation and intraoperative therapies.
  • Eligibility for P/D depends on the stage of the disease, lymph node involvement, and how affected the lung is by tumors.
  • Survival rates for mesothelioma P/D are as high as 32 months in some studies.

How to Get a Pleurectomy With Decortication for Your Mesothelioma

The easiest way to get a P/D for your mesothelioma is by contacting our staff. Mesothelioma is a rare disease, and many doctors aren’t familiar with P/D surgery. Patient advocates can guide you through finding a doctor or cancer center with experience treating mesothelioma:

1

Our patient advocates will help you contact a cancer center and schedule your first meeting. This initial consultation is often done virtually to reduce travel time and costs.

2

Once you meet with a mesothelioma surgeon or oncologist, they’ll explain the next steps. If you aren’t diagnosed yet, you’ll go through the diagnostic process. This includes getting a biopsy, which is a noninvasive surgery.

3

Once you’re diagnosed, doctors will examine your disease and health. These factors help doctors decide whether you’ll benefit from surgery. If so, they’ll determine whether a pleurectomy with decortication is the best option.

Overview of Pleurectomy With Decortication for Pleural Mesothelioma

Surgery for mesothelioma is intended to remove all visible cancer cells. Surgical options include pleurectomy with decortication (P/D) and extrapleural pneumonectomy (EPP). Pleurectomy with decortication is an alternative to extrapleural pneumonectomy and keeps both lungs intact.

Where Was P/D for Mesothelioma Developed?

Multiple cancer centers and doctors played a role in developing P/D for mesothelioma. The surgery was popularized in the 1990s as an alternative to EPP. These cancer centers include:

What Is Pleurectomy?

Pleurectomy is a surgery to remove the area where pleural mesothelioma forms. Doctors remove part of the diseased lining near a patient’s lung. This lining is called the pleura. Removing part of the pleura is called “pleurectomy.”

The late Dr. David Sugarbaker called P/D “like peeling an orange.” Surgeons peel the outer pleural lining (parietal pleura) off the chest wall. This strips tumors off the chest wall.

What Is Decortication?

Doctors peel the inner pleural lining (visceral pleura) off of the lung. This removes tumors from the surface of the organ. Surgeons also remove other visible tumors in the chest cavity during P/D. This process is called “decortication” or “cytoreduction.”

What Is the Pleura?

The pleura is a thin lining on the inside of the chest wall and outer surface of the lung. It separates the chest wall and lung cavity. The pleura produces and absorbs a lubricant to assist with breathing.

It includes two layers of tissue: the parietal pleura (next to the chest wall) and visceral pleura (next to the lung). Both produce and absorb fluid daily, allowing the lung to glide within the chest (thorax).

These cells entrap asbestos fibers, which irritate the cells and cause mutation. This is how pleural mesothelioma forms. Asbestos is a light fiber that can get caught in the lung or make its way into the pleura.

Any aggressive pleural mesothelioma surgery starts with removing the pleura. The original tumor forms in this location. As tumors grow and duplicate in this lining, fluid builds up and causes discomfort for patients. Eventually, tumors spread beyond the pleura and reach the lungs.

P/D starts with removing the pleura off the chest wall. The surgeon then determines if it’s possible to peel the pleura and visible tumors off the lung (P/D) or if the lung must be removed (EPP).

Radical P/D for Pleural Mesothelioma

There’s also an extended version of P/D. This is also called radical pleurectomy with decortication.

Along with the pleura, surgeons may remove:

  • Part or all of the diaphragm
  • The pericardium (lining around the heart)

This version of P/D lets doctors remove more at‑risk areas. This increases the chances of completely resecting mesothelioma and decreases the chances of recurrence.

Many doctors prefer radical pleurectomy over the traditional version, which is also called a partial pleurectomy.

Comparing P/D and EPP for Mesothelioma

EPP is the original surgery for pleural mesothelioma. It targets the affected lung in addition to the pleura, diaphragm and pericardium. For many years, doctors felt removing the lung was the only way to address mesothelioma.

Most mesothelioma specialists now prefer P/D over EPP, when technically possible, for three reasons:

  • The immediate risk associated with P/D surgery is lower
  • Long‑term survival is similar
  • Quality of life is often better

Dr. Raja Flores, the director of thoracic surgery at Mount Sinai Medical Center, is one of many who prefers P/D when possible.

“What we’re finding is the most important thing is to preserve that lung,” he said.

P/D can improve the patient’s breathing, stop fatigue and eliminate fluid buildup that occurs in the pleura.

Multimodal and Intraoperative Treatments With P/D

Specialists usually combine P/D with other mesothelioma treatment options. This creates a multimodal treatment, which is best for survival.

Pleurectomy with decortication works best with chemotherapy and radiation. Doctors are investigating immunotherapy with P/D. These are traditionally used after P/D surgery, but more cancer centers are testing them beforehand as well.

Intraoperative therapies also are on the rise with mesothelioma P/D. These methods allow specialists to apply treatments directly at the tumor site right after surgery. This approach:

  • Reduces side effects
  • Improves the chances of complete disease eradication

The two intraoperative therapies used with P/D are:

  • Hyperthermic intraoperative chemotherapy (HIOC), also called hyperthermic intrathoracic chemotherapy (HITHOC)
  • Intraoperative radiation therapy (IORT)

What Happens During a Pleurectomy With Decortication for Mesothelioma?

Prior to surgery, doctors use anesthesia to put the patient to sleep. The anesthesiologist then uses an endotracheal or breathing tube to ensure adequate air intake to the lungs and a catheter will be placed to monitor urine output.

This process can take 60‑90 minutes prior to an incision. The patient is under anesthesia for 6‑12 hours.

8 Steps of Pleurectomy With Decortication for Mesothelioma

The procedure, from the first incision to the last stitch, takes several hours:

1

Incision — The incision is made from the patient’s back to under the pectoral muscle. This allows the surgeon to enter the chest cavity. The sixth rib is usually removed. This incision is called a thoracotomy.

2

Parietal Pleurectomy — The parietal (outer) pleura is removed. Surgeons lay the patient on their side for easy access to the chest. They also take out diseased tissue along the chest wall, diaphragm and pericardium. If the tumors invade an area that cannot be safely removed, the surgeon will likely stop the surgery.

3

Visceral Pleurectomy — The visceral (inner) pleura is separated from the lung. It’s a time‑consuming process since protecting the lung is a priority.

4

Decortication — Surgeons remove all visible tumors. If this isn’t possible, the surgeon will consider EPP. This step is the most tedious one and often determines if the patient has a complete resection.

5

Lymph node removal — Mesothelioma may spread to lymph nodes in the chest. If so, surgeons remove the affected ones from specific areas.

6

Possible additional treatments and therapies — Some cancer centers utilize intraoperative chemotherapy, intraoperative radiotherapy, photodynamic therapy and cryotherapy during surgery. These therapies allow doctors direct access to treat non‑visible cancer cells.

7

Reconstruction — Doctors may use Gore‑Tex or another substance to reconstruct the diaphragm. Stitches are used to close the chest.

8

Cavity examination and lung repair — Doctors insert chest tubes to ensure the lung re‑expands normally. This also ensures proper drainage of the space where the pleura once was. These tubes are critical for healthy recovery.

Recovery Time After P/D for Mesothelioma

P/D mesothelioma patients should expect a surgical recovery of around 1‑2 months. They’ll spend 10‑14 days in the hospital after surgery. Outpatient recovery takes an additional 2‑6 weeks.

Inpatient P/D Recovery

Following surgery, most patients go to the intensive care unit (ICU). They’ll still have a breathing tube and doctors will ensure the lung is fully inflated.

Patients are encouraged to start walking and move as soon as possible. Doctors also recommend breathing and coughing exercises. They can:

  • Increase lung ventilation
  • Prevent infection, blood clots and pneumonia
  • Defend against sputum (mucus) buildup

The patient’s recovery success, support system and other factors will affect their discharge time. A successful P/D leads to air leaks in the lung. This can prolong inpatient recovery.

Outpatient P/D Recovery

Outpatient recovery occurs either at the patient’s home or an acute care rehabilitation facility. The outpatient recovery time varies. Patients should continue their breathing exercises and physical activity.

Once the recovery time finishes, patients can assume a normal life but must avoid overexertion.

Who Can Get P/D for Their Mesothelioma?

Performing mesothelioma P/D is a judgment call, and there’s no formula to determine who is eligible. If you’re told you have an inoperable disease, you may want to obtain a second opinion. Mesothelioma P/D is nuanced and should be performed by a thoracic surgeon.

P/D Eligibility: Stage

Stage of mesothelioma is the most crucial factor for determining who can get P/D. Cancer stage is based on how far the disease has spread.

If the cancer is in an early stage, such as stage 1 or stage 2, then P/D is usually the best option. Stage 1 does not involve any tumors in the lungs. The cancer is contained within the pleura, which means removing this lining will help.

In stage 2 mesothelioma, there may be tumors in the lungs. Doctors still prefer P/D since peeling the pleura off the lung removes many tumors on the organ.

Some doctors may feel EPP is the best option for stage 3 patients. The lung may have too many tumors, and doctors might feel it’s best to take the lung out of the body. Others, like Dr. Flores, feel differently. P/D can be better for quality of life, even in stage 3.

“We thought that maybe for stage 3, EPP would be better,” Dr. Flores said, “but that wasn’t true.”

With stage 4 mesothelioma, the disease is usually too advanced for P/D surgery.

P/D Eligibility: Physical Health

Aside from the stage, physical health is the next most important factor. Before undergoing any major surgery, patients should be physically fit enough to handle P/D. They must endure the stress and recovery of the operation.

Patients are monitored beforehand to ensure they’re capable of handling the procedure. This screening is essential for reducing the mortality rate.

Preoperative Patient Evaluation for Mesothelioma P/D

  • Age and fitness evaluation
  • Blood tests
  • Pulmonary function evaluation
  • Ventilation/perfusion scan
  • CT scan, MRI of the chest and PET scan
  • Echocardiogram
  • Stress test

P/D Eligibility: Cell Type

Patients with epithelioid mesothelioma are the best candidates for P/D. This cell type is the most common and easily treated with surgery. Sarcomatoid mesothelioma is tougher to treat with surgery.

Doctors perform a pleural biopsy to determine the cell type. This is part of the diagnostic process.

Life Expectancy and Survival Rates for P/D

Since its development in the 1990s, mesothelioma survival rates for P/D have improved.

In 2008, Dr. Flores led a study that resulted in median survival of 16 months. Even then, P/D bested EPP by four months.

In the most recent study, authored by Dr. Raphael Bueno of Brigham and Women’s Hospital:

  • Successful P/D had a median survival of 23 months
  • The five‑year survival rate was 21%

This data is promising, but mesothelioma stage and cell type play a significant role. Stage 1 mesothelioma and epithelioid cell type have the longest survival. The median survival for this combination is 70 months, and the five‑year survival rate is 54%.

Dr. Anne Tsao, of MD Anderson Cancer Center in Houston, co‑authored a study comparing survival for P/D and EPP. The survival rate for nearly 100 patients after P/D was 22 months.

Survival Statistics for Extended P/D

Extended P/D is gaining popularity for stage 2 and stage 3 pleural mesothelioma. For the earliest stage, normal P/D is usually the preference because the tumors haven’t spread beyond the pleura.

When tumors have left the pleura, extended P/D reduces recurrence rates and helps resect more of the disease. It’s also safer than EPP. Extended P/D has a 30‑day mortality rate of around 3%.

In one study, extended pleurectomy with decortication had survival of 20 months. Other studies show survival of 2‑3 years.

Survival After P/D With Multimodal Treatment

Mesothelioma P/D on its own often isn’t enough. Doctors recommend chemotherapy, radiation and even immunotherapy as a secondary treatment.

Multimodal treatment involves multiple lines of therapy. Surgery is the primary treatment. Chemotherapy and radiation address non‑visible tumors on the margins.

Doctors may use chemotherapy, radiation or immunotherapy before or after the surgery. Traditionally, they were used after surgery (adjuvant treatment). More cancer centers today are testing these therapies before surgery (neoadjuvant treatment).

Multimodal treatment only improves the effectiveness of mesothelioma pleurectomy with decortication:

  • P/D with neoadjuvant chemotherapy and adjuvant radiation — 23.7 months median survival and 59% two‑year survival rate
  • P/D with neoadjuvant and adjuvant chemotherapy — 32 months median survival, 63% two‑year survival rate and 23% five‑year survival rate
  • Extended P/D with adjuvant chemotherapy and radiation — 32 months median survival and 25% five‑year survival rate
  • P/D with hyperthermic intrathoracic chemoperfusion — 16 months median survival, 40% two‑year survival rate and 20% five‑year survival rate

Survival After Intraoperative Therapies With P/D

Mesothelioma treatment continues evolving with time. A new facet is intraoperative therapy, such as chemotherapy or radiation.

P/D With HITHOC for Mesothelioma

For intraoperative chemotherapy, doctors apply a hot liquid chemotherapy directly into the cancer site. This is called heated intraoperative chemotherapy (HIOC) or heated intrathoracic chemotherapy (HITHOC). For pleurectomy with decortication, doctors apply HITHOC into the pleural space or thorax.

The purpose is to subject mesothelioma cells to chemotherapy drugs quickly. HITHOC also avoids sending chemotherapy through the blood system. This keeps the chemotherapy away from healthy cells.

In one study, P/D plus HITHOC led to a remarkable median survival of 42 months. Extended P/D plus HITHOC led to a median survival of 28 months.

P/D With IORT for Mesothelioma

Another option is intraoperative radiation therapy (IORT). This method sends radiation beams directly to the tumor site.

IORT avoids passing through healthy skin and tissue to reach the target. This reduces the damage to healthy tissue or lung scarring.

In one study, pleurectomy with decortication plus IORT had a median survival of 18 months. Around 64% of patients survived for one year.

Possible Pleurectomy With Decortication Complications

As with any surgery, there are risks associated with P/D for mesothelioma. The first is deciding either P/D or EPP. In some cases, P/D isn’t aggressive enough to remove all the tumors.

The next risk is any long‑term side effects from a pleurectomy with decortication.

Mesothelioma Recurrence After P/D

Mesothelioma has a high rate of recurrence. For incomplete pleurectomy with decortication, the risk is notable. The rate of recurrence decreases for a complete P/D or extended P/D.

Dr. Flores researched the chances of recurrence. For extrapleural pneumonectomy, around 57% of patients experience recurrence. The rate is the same for pleurectomy with decortication, but with both lungs intact, they can better handle treatment.

“The recurrence sometimes occurs in the other lung,” Dr. Flores said, noting that EPP would leave “no reserves” for the patient. “So now you’ve painted yourself into a corner.”

Mortality From Mesothelioma P/D

Some risks may lead to intraoperative or postoperative mortality. In Dr. Flores’ study, the 30‑day mortality from P/D was only 1.7%.

Dr. Tsao extraordinarily reported a perioperative mortality rate of 0% among 95 patients, meaning none of them died within 30 days after P/D surgery.

These rates are much better than EPP’s mortality rates of between 4% and 11%, depending on the study.

While mortality for P/D is lower, it’s important to note there are some risks. The primary health complications for mesothelioma pleurectomy with decortication are:

  • Internal bleeding
  • Pneumonia
  • Blood clots
  • Respiratory failure
  • Infection
  • Cardiac failure
  • Pneumothorax (collapsed lung due to air leaking)

Quality of Life After Mesothelioma P/D

While some physical aspects never return to normal following P/D — or any mesothelioma surgery — there’s a quality of life benefit.

Researchers in Japan analyzed the impact of P/D surgery on quality of life. Lung function never fully recovered following the surgery, but there was a significant decrease in body pain from before to after the operation. Other improvements or returns to pre‑diagnosis levels were:

  • Social function
  • Mental health
  • Energy levels

Doctors Who Perform P/D for Pleural Mesothelioma

There are doctors in every region of the country who can perform this surgery. Dr. Avi Lebenthal at Brigham and Women’s Hospital in Boston is one of the leaders in the field of P/D for mesothelioma.

A few more specialists who perform P/D for mesothelioma are:

  • Dr. Raja Flores, Mount Sinai Medical Center (New York, New York)
  • Dr. Marcelo DaSilva, AdventHealth (Orlando, Florida)
  • Dr. Robert Cameron, UCLA Medical Center (Los Angeles, California)
  • Dr. Taylor Ripley, Baylor St. Luke’s Medical Center (Houston, Texas)
  • Dr. Elliot Wakeam, Michigan Medicine (Ann Arbor, Michigan)

Finding Surgical Treatment in the VA Health Care System

A lot of veterans with mesothelioma don’t see a specialist. They instead rely on a general oncologist, who might not know how to treat mesothelioma. This lack of experience could cause veterans to miss out on a longer life.

The U.S. Department of Veterans Affairs has three hospitals with mesothelioma programs. These hospitals are specifically for veterans with VA health insurance, which is free. For most veterans with mesothelioma, VA health care is free of copays.

The three VA hospitals treating mesothelioma are:

Dr. Hassan Khalil leads mesothelioma treatment at the Boston VA. Dr. Taylor Ripley, with the help of Dr. Lorraine Cornwell, heads the Houston VA program. Both centers offer mesothelioma pleurectomy with decortication as a surgical option for veterans.

If you need help signing up for VA health insurance or contacting any of these VA hospitals, reach out to LCDR Carl Jewett. Carl is a veterans support advocate who has close connections with mesothelioma surgeons.

Common Questions About Pleurectomy With Decortication for Mesothelioma

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What is a pleurectomy with decortication?

Pleurectomy with decortication is a two‑part procedure for malignant pleural mesothelioma. Pleurectomy involves removing the pleura, which is the thin lining between your lung cavity and chest wall. It’s where pleural mesothelioma forms. Decortication is removing the surface layer or fibrous cover of an organ, stripping away any visible tumors.

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What is the survival for pleurectomy with decortication?

Dr. Raja Flores, a highly respected mesothelioma surgeon, reported a five‑year survival rate of 40% after pleurectomy with decortication. This outcome is more promising than the five‑year survival average of all pleural mesothelioma cases, which is around 5%.

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How long does pleurectomy with decortication take?

Pleurectomy with decortication for mesothelioma takes around 2‑4 hours. The procedure’s length depends on how many tumors are attached to the nearby lung and whether surgeons remove the diaphragm and pericardium. A regular pleurectomy with decortication takes less time than an extended version of this surgery.

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What is the recovery time for pleurectomy with decortication?

Pleurectomy with decortication usually has a shorter surgical recovery time. Patients will receive inpatient care for around one week following surgery, and 4‑8 weeks of outpatient recovery. Most patients fully recover and feel back to normal within two months.

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How much does pleurectomy with decortication for mesothelioma cost?

According to a report published by Rare Tumors, the median cost for a mesothelioma pleurectomy with decortication was around $53,000. The range is between $43,000 and $65,000. Health Insurance helps patients cover at least the majority of the surgery’s cost.

Sources & Author

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About the Writer, Karen Ritter, RN BSN

Karen Ritter is a registered nurse and patient advocate for Mesothelioma Guide. She leads patients and families through their mesothelioma diagnosis, explaining treatments and support options. Karen joined Mesothelioma Guide in 2021.