Written By: Karen Ritter, RN BSN

Mesothelioma Pleurectomy With Decortication (P/D)

Pleurectomy with decortication (P/D) is surgery for patients with malignant pleural mesothelioma. The surgery is performed on one side of the chest, removing the pleura but leaving both lungs intact.

Dr. Abraham Lebenthal

Medically Reviewed By

Dr. Abraham Lebenthal

Mesothelioma Thoracic Surgeon

Dr. Abraham Lebenthal

Medically Reviewed By

Dr. Abraham Lebenthal

Mesothelioma Thoracic Surgeon


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Important Facts About Mesothelioma Pleurectomy With Decortication

  • P/D is a two-part surgical procedure to treat pleural mesothelioma: pleurectomy and decortication. It removes the lining of the lung (pleura). This is called the lung-sparing surgery.
  • An “extended” or “radical” version of P/D removes part of the diaphragm and the pericardium (lining around the heart) along with the pleura.
  • Doctors may combine P/D surgery with systemic or intraoperative chemotherapy for malignant pleural mesothelioma.
  • Eligibility for P/D surgery depends on the stage of the disease and health of the patient.
  • Survival after P/D is as high as 32 months in some studies

How to Get a Pleurectomy and Decortication Surgery for Your Mesothelioma

Finding mesothelioma specialists is a crucial step after being diagnosed with pleural mesothelioma. Mesothelioma is a rare disease, and many doctors do not have the experience and knowledge needed to treat it. Our patient advocates can guide you through finding mesothelioma doctors and cancer centers with experience:

  1. Our patient advocates help you contact a cancer center and assist in connecting you with mesothelioma specialists. A virtual consultation may be available to reduce travel time and costs.
  2. Once you meet with a mesothelioma surgeon and oncologist, they’ll explain the next steps. If you haven’t been diagnosed yet, you’ll go through the diagnostic process. This includes getting a biopsy.
  3. Once you’re diagnosed, doctors will determine the details of your disease and your overall 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

Pleurectomy decortication surgery is intended to remove all visible mesothelioma tumors. The surgery is an alternative to extrapleural pneumonectomy, which removes a lung. It involves removing the pleural lining and any diseased tissue.

Where Was P/D Surgery Developed?

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

What Is Pleurectomy?

Pleurectomy is a surgery to remove part of the pleura, the lining of the patient’s lung. This is the area where pleural mesothelioma forms.

Dr. David Sugarbaker called a pleurectomy “like peeling an orange.” Surgeons peel the outer pleural lining (parietal pleura) off of the chest wall. This strips tumors from the wall of the thoracic cavity.

What Is Decortication?

Decortication is the peeling of the inner pleural lining (visceral pleura) off the surface of the lung. Surgeons also remove other visible tumors in the chest cavity during decortication.

 What Is the Pleura?

The pleura is a thin lining on the inside of the chest wall and on the outer surface of the lung. It separates the chest wall and lungs. The pleura produces and absorbs a lubricant to assist with breathing. This fluid provides a buffer to allow the lung to expand and inflate without friction.

The pleura includes two layers of tissue: the parietal pleura (next to the chest wall) and the visceral pleura (next to the lung). Both produce fluid that allows the lung to glide, expand and move, within the chest cavity.

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 to the lung tissue.

Radical P/D for Pleural Mesothelioma

The extended version of P/D is also called radical pleurectomy/decortication. This is a more aggressive surgery than standard P/D, which is sometimes called a “partial pleurectomy.” 

Along with the pleura, surgeons performing radical P/D may remove:

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

This operative technique of P/D increases the chances of complete resection of malignant mesothelioma of the pleura. It decreases the chances of recurrence but is more challenging for some patients.

Comparing P/D and EPP Surgeries

Extrapleural pneumonectomy (EPP) is the original surgery for the management of malignant 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 specialists now prefer P/D over EPP, when technically possible, for three reasons:

  • Mortality risk is lower
  • Long-term survival is similar
  • Quality of life is often better 

Dr. Raja Flores, the chief of thoracic surgery at Mount Sinai Medical Center, is one of many mesothelioma specialists who prefer P/D.

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

A report compared the number of P/D and EPP surgeries in the last few years. P/D is overtaking EPP as the most used surgery for mesothelioma.

From 1995-2012, around 53% of mesothelioma surgery cases used EPP. From 2007-2017, 81% of surgery cases used P/D instead.

A study recently published in the Annals of Thoracic Surgery detailed survival trends for each pleural mesothelioma surgery. One of the co-authors, Dr. Anne Tsao, is a renowned mesothelioma specialist at MD Anderson Cancer Center in Houston, Texas.

Most patients in the study underwent EPP (66%), but the survival favored P/D surgery. The lung-sparing option had a median survival of 22 months, compared to just 15 months for EPP.

Multimodal and Intraoperative Treatments With P/D

Specialists usually combine pleurectomy/decortication with other mesothelioma treatment options. This is called multimodal treatment, which is best for survival.

Pleurectomy and decortication is often paired with chemotherapy, immunotherapy or radiation.

Treatment of malignant pleural mesothelioma can also include intraoperative therapies. These methods involve a two-part surgery, removal of the tumors and the administration of treatments directly into the surgical site.  This approach:

  • Reduces side effects
  • Improves the success of surgery for pleural mesothelioma

Two intraoperative therapies used with pleurectomy/decortication are:

  • Hyperthermic intrathoracic chemotherapy (HITHOC)
  • Intraoperative radiation therapy (IORT)

What Happens During a Pleurectomy/Decortication?

Surgery for malignant pleural mesothelioma starts with doctors using anesthesia to put the patient to sleep. The anesthesiologist places a breathing tube to ensure adequate oxygen for the patient and closely monitors the patient throughout the surgery..

The patient is often under anesthesia for 6-12 hours.

7 Steps of Pleurectomy/Decortication for Mesothelioma

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

  1. Incision — The patient is carefully placed on their side so the surgeon has easy access to the chest. A thoracotomy 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 open that access.
  2. Parietal Pleurectomy — The parietal (outer) pleura is removed. They also take out diseased tissue along the chest wall, diaphragm and pericardium. If the tumors have invaded an area that cannot be safely removed, the surgeon may stop the surgery.
  3. Decortication — Surgeons remove all visible tumors. Decortication also includes visceral pleurectomy. The visceral (inner) pleura is separated from the lung surface. It’s a time-consuming process since protecting the lung tissue is a priority.
  4. Lymph node removal — Mesothelioma may spread to lymph nodes in the chest. The surgeon will remove multiple lymph nodes from the chest region to help determine if there is pleural metastases.
  5. Possible additional treatments and therapies — Some cancer centers utilize intraoperative chemotherapy, intraoperative radiotherapy, photodynamic therapy or cryotherapy.
  6. Reconstruction — Doctors may use Gore-Tex or other mesh products to perform reconstruction of the diaphragm. Sutures close the chest.
  7. 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.

Recovery Time After Pleurectomy and Decortication

P/D surgery for mesothelioma patients should expect recovery to last 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 P/D, surgical management of malignant pleural mesothelioma, most patients go to the intensive care unit (ICU). They may still have a breathing tube, and doctors will ensure the lung is fully inflated.

Patients are encouraged to start walking 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

P/D surgery may lead to air leaks in the lungs. This may prolong the inpatient recovery stay.

Outpatient P/D Recovery

Patients who undergo P/D surgery will be discharged from the hospital to continue recovery in the outpatient setting. This can be in the patient’s home or a rehabilitation facility. The outpatient recovery time varies per patient. Patients will need to continue to rest, heal and perform their breathing exercises and physical therapy to increase their strength and mobility.

Who Can Get Pleurectomy/Decortication Surgery?

Pleural mesothelioma patients go through a vetting and evaluation process to determine if they are eligible for pleurectomy/decortication surgery. Many patients with diffuse malignant pleural mesothelioma will have inoperable disease. A mesothelioma diagnosis requires a comprehensive evaluation by a mesothelioma specialist to determine if surgery is possible.

P/D Eligibility: Stage

The stage of mesothelioma is one of the most crucial factors that determine surgical eligibility. Cancer staging is based on how far the disease has spread.

If the cancer is an early-stage pleural mesothelioma, such as stage 1 or stage 2, then P/D is an option. Stage 1 mesothelioma is contained within the pleura, the lining of the lung.

In stage 2, there may be tumors found beyond the pleura into the lung tissue. Doctors may still recommend P/D since peeling the pleura off the lung can be effective in resecting the cancer and saving the lung. 

Some doctors feel EPP surgery is the best option for stage 3. The lung may have too many tumors, and doctors might feel it’s best to take the entire lung out. Others feel differently. P/D may provide for an easier recovery and a better 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 any surgery. 

P/D Eligibility: Cell Type

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

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

P/D Eligibility: Physical Health

Aside from the stage, physical health is the next most important factor used in selecting patients for surgery. Before undergoing any major surgery, patients should be in good physical health. They must endure the stress of surgery and be able to regain their strength to achieve total recovery after surgery. 

Mesothelioma patients must be monitored before surgery to ensure they are able to handle the procedure. This screening process is essential for reducing complications. 

Preoperative Patient Evaluation for P/D

  • Age and health evaluation
  • Blood tests
  • Pulmonary function evaluation
  • Ventilation/perfusion scan
  • Imaging scans
  • Echocardiogram
  • Stress test

Life Expectancy and Survival Rates for P/D

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

In 2008, Dr. Flores led a study resulting in a median survival of 16 months. In a recent study, co-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%

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.

For patients with biphasic mesothelioma, the median survival was 16 months. This was reported in another study by Dr. Bueno. It was 24 months for patients younger than age 70, though.

Video-Assisted, Minimally Invasive P/D

Video-assisted, minimally invasive P/D is called VATS-P/D. VATS stands for “video-assisted thoracoscopic surgery.” This is a subdued form of P/D surgery, as doctors use a needle-sized incision to drain the pleural space of excess fluid. The average survival time is only 14 months, but there are a lot of benefits.

“Patients who undergo VATS P/D have better short-term outcomes compared to those who undergo curative attempts at surgery,” wrote Dr. Raja Flores, of Mount Sinai Cancer Center, in a study report. “Therefore, VATS P/D should be considered in the armamentarium of treatment for MPM, especially in older and frailer patients who may not tolerate more radical surgery.”

This approach leads to fewer post-operative complications for patients. VATS-P/D also had a higher median age (71.8 versus 69.1), which is why some doctors believe it’s a good choice for elderly and late-stage patients.

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 or “partial” P/D is usually the preference because 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 led to a median survival of 20 months. Other studies report survival of 2-3 years.

P/D With Multimodal Treatment

P/D surgery for mesothelioma often isn’t enough. Doctors recommend chemotherapy, radiation and even immunotherapy as secondary treatments.

Multimodal treatment involves multiple lines of therapy. Surgery is the primary treatment. Other therapies address non-visible tumors or ones along the chest wall or lungs.

Doctors may use chemotherapy, radiation or immunotherapy before or after the surgery. Before is called neoadjuvant treatment, and after is called adjuvant treatment.

Multimodal treatment is intended to help patients survive longer after mesothelioma P/D surgery:

  • 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

Intraoperative Therapies Used With P/D

Mesothelioma treatment continues to evolve with time. A new facet is intraoperative therapy, which uses chemotherapy or radiation during radical surgery for patients diagnosed with mesothelioma. 


For intraoperative chemotherapy, doctors apply hot liquid chemotherapy directly into the cancer-affected area. For pleurectomy with decortication, doctors place heated intrathoracic chemotherapy (HITHOC) into the chest cavity.

The purpose is to subject mesothelioma cancer cells to chemotherapy drugs directly. HITHOC also avoids sending chemotherapy through the blood system. This can also help prevent chemotherapy from damaging healthy cells in the body.

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


Another option is intraoperative radiation therapy (IORT). This method sends radiation beams directly into the chest cavity.

IORT avoids passing radiation through healthy skin and tissue to reach the targeted cancer tumors. This reduces the damage to healthy tissue and widespread 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 Complications From Pleurectomy/Decortication

As with any surgery, there are risks associated with P/D. The biggest is any long-term side effects from a pleurectomy/decortication.

Some risks may lead to intraoperative or postoperative mortality. In multiple studies, the mortality rates were between 1.7% and 3%. These figures are much better than EPP’s mortality rates of 4% and 11%, depending on the study.

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

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

Mesothelioma Recurrence After P/D

Mesothelioma has a high rate of recurrence. For incomplete pleurectomy/decortication, the risk is notable. In some cases, pleurectomy/decortication surgery isn’t aggressive enough to remove enough tumors. The rate of recurrence decreases with the complete P/D or an 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, patients can better handle follow-up treatments.

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

Quality of Life After P/D Surgery

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 after the operation. Other improvements or returns to pre-surgery 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 operation. You can usually find a nearby specialist for P/D surgery no matter where you live.

A few specialists who perform pleurectomy/decortication for mesothelioma are:

Finding Surgical Treatment in the VA Health Care System

Veterans diagnosed with mesothelioma typically do not see a specialist. They instead rely on a general oncologist, who may not have the knowledge to effectively treat diffuse malignant 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.

 Dr. Taylor Ripley, with the help of Dr. Lorraine Cornwell, heads the Houston VA program and Dr. Robert Cameron sees patients at the West Los Angeles VA Medical Center. Both centers offer pleurectomy/decortication as a surgical option for veterans with pleural mesothelioma.

 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.

Frequently Asked 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

  1. Pleurectomy Decortication in the Treatment of Malignant Pleural Mesothelioma. Annals of Surgery. Retrieved from: https://journals.lww.com/annalsofsurgery/Abstract/9000/Pleurectomy_Decortication_in_the_Treatment_of.93886.aspx. Accessed: 12/07/2020.
  2. Extrapleural pneumonectomy (EPP) vs. pleurectomy decortication (P/D). Annals of Translational Medicine. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5497106/. Accessed: 12/07/2020.
  3. Pleurectomy/decortication and hyperthermic intrathoracic chemoperfusion using cisplatin and doxorubicin for malignant pleural mesothelioma. Journal of Thoracic Disease. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/31285889. Accessed: 07/18/19.
  4. Radical pleurectomy/decortication and intraoperative radiotherapy followed by conformal radiation with or without chemotherapy for malignant pleural mesothelioma. The Journal of Thoracic and Cardiovascular Surgery. Retrieved from: https://www.sciencedirect.com/science/article/pii/S0022522302003240. Accessed: 01/22/2021.
  5. A pilot trial of high-dose-rate intraoperative radiation therapy for malignant pleural mesothelioma. American Brachytherapy Society. Retrieved from: https://www.brachyjournal.com/article/S1538-4721(04)00213-2/abstract. Accessed: 01/22/2021.
  6. Pleurectomy/decortication and hyperthermic intrathoracic chemoperfusion using cisplatin and doxorubicin for malignant pleural mesothelioma. Journal of Thoracic Disease. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6588772/. Accessed: 01/22/2021.
  7. A Phase III Randomized Trial of Pleurectomy/Decortication Plus Chemotherapy With or Without Adjuvant Hemithoracic Intensity-Modulated Pleural Radiation Therapy (IMPRINT) for Malignant Pleural Mesothelioma (MPM) (NRG LU-006). International Journal of Radiation Oncology. Retrieved from: https://www.redjournal.org/article/S0360-3016(21)02168-4/fulltext#relatedArticles. Accessed: 10/31/2021.
  8. Hyperthermic intrathoracic chemotherapy (HITHOC) should be included in the guidelines for malignant pleural mesothelioma. Annals of Translational Medicine. Retrieved from: https://atm.amegroups.com/article/view/60185/pdf. Accessed: 01/26/2021.
  9. Systematic Review and Meta-Analysis of Pleurectomy/Decortication versus Extrapleural Pneumonectomy in the Treatment of Malignant Pleural Mesothelioma. Journal of Clinical Medicine. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/36233416/. Acessed: 10/18/2022.
  10. 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.
  11. VATS Pleurectomy Decortication Is a Reasonable Alternative for Higher Risk Patients in the Management of Malignant Pleural Mesothelioma: An Analysis of Short-Term Outcomes. MDPI. Retrieved from: https://www.mdpi.com/2072-6694/13/5/1068/htm. Accessed: 04/06/2021.
  12. Quality of life and lung function after pleurectomy/decortication for malignant pleural mesothelioma. Interactive Cardiovascular and Thoracic Surgery. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/33963844/. Accessed: 05/24/2021.
  13. Costs of medical care for mesothelioma. Rare Tumors. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6637828/. Accessed: 06/23/2021.
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About the Writer, Karen Ritter, RN BSN

Karen Ritter, a registered nurse, is the lead patient advocate for Mesothelioma Guide. She has a deep passion for patient care, which includes helping patients and their families search for treatment options at the top mesothelioma cancer centers. She finds the balance between encouraging patients to receive the best treatment possible while enjoying their time with loved ones and friends. Karen is a valuable asset for patients due to her knowledge of mesothelioma, compassion for the victims of this disease and dedication to guiding patients through their treatment journey.