Written By: Karen Ritter, RN BSN
Mesothelioma Pleurectomy With Decortication (P/D)
Mesothelioma pleurectomy with decortication (P/D) is surgery for patients with pleural mesothelioma. The surgery is performed on one side of the chest, removing the pleura but leaving both lungs intact.
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Important Facts About Mesothelioma Pleurectomy With Decortication
- P/D is a two-part procedure for mesothelioma: pleurectomy and decortication. It removes the lining near the lungs.
- An “extended” or “radical” version of P/D removes the diaphragm and pericardium (lining around the heart).
- Doctors may combine P/D with systemic or intraoperative therapies.
- Eligibility for P/D surgery depends on the stage of the disease and health of the lungs.
- Survival after P/D is as high as 32 months in some studies.
How to Get P/D Surgery for Mesothelioma
The easiest way to get P/D surgery for mesothelioma is by contacting our staff. Mesothelioma is a rare disease, and many doctors aren’t familiar with how to treat it. Patient advocates can guide you through finding a doctor or cancer center with experience:
Our patient advocates help you contact a cancer center and schedule your first meeting. This initial consultation is often done virtually to reduce travel time and costs.
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.
Once you’re diagnosed, doctors 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
P/D surgery is intended to remove all visible cancer cells. The surgery is an alternative to extrapleural pneumonectomy, which removes a lung.
Where Was P/D Surgery Developed?
Multiple cancer centers and doctors played a role in developing P/D. The surgery was popularized in the 1990s as an alternative to EPP. The leading cancer centers for performing P/D include:
- Brigham and Women’s Hospital in Boston, Massachusetts
- Memorial Sloan Kettering Cancer Center in New York, New York
- Mount Sinai Medical Center in New York, New York
- UCLA Medical Center in Los Angeles, California
What Is Pleurectomy?
Pleurectomy is a surgery to remove part of the pleura, a lining near 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 off tumors from the wall.
What Is Decortication?
Decortication is peeling 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 decortication.
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.
The pleura 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).
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.
Radical P/D for Pleural Mesothelioma
The extended version of P/D is also called radical pleurectomy with 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 version of P/D increases the chances of completely resecting mesothelioma. It decreases the chances of recurrence but is more taxing for some patients.
Comparing P/D and EPP Surgeries
Extrapleural pneumonectomy (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 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 director of thoracic surgery at Mount Sinai Medical Center, is one of many who prefers P/D.
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.
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 far 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 P/D with other mesothelioma treatment options. This is called multimodal treatment, which is best for survival.
The surgery works best with chemotherapy and radiation. Doctors are investigating immunotherapy with P/D.
Intraoperative therapies are also on the rise with P/D. These methods allow specialists to apply treatments directly to the tumor site right after surgery. This approach:
- Reduces side effects
- Improves the chances of complete resection
Two intraoperative therapies used with P/D are:
- Hyperthermic intrathoracic chemotherapy (HITHOC)
- Intraoperative radiation therapy (IORT)
What Happens During a Pleurectomy With Decortication?
Prior to surgery, doctors use anesthesia to put the patient to sleep. The anesthesiologist then uses a breathing tube to provide adequate air intake to the lungs. A catheter is used to monitor urine output.
This process can take 60‑90 minutes prior to an incision. The patient is under anesthesia for 6‑12 hours.
7 Steps of Pleurectomy With Decortication for Mesothelioma
The procedure, from the first incision to the last stitch, takes several hours:
Incision — 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.
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 have invaded an area that cannot be safely removed, the surgeon may stop the surgery.
Decortication — Surgeons remove all visible tumors. If this isn’t possible, the surgeon will consider EPP. Decortication also includes visceral pleurectomy. The visceral (inner) pleura is separated from the lung. It’s a time-consuming process since protecting the lung is a priority.
Lymph node removal — Mesothelioma may spread to lymph nodes in the chest. If so, surgeons remove the affected ones.
Possible additional treatments and therapies — Some cancer centers utilize intraoperative chemotherapy, intraoperative radiotherapy, photodynamic therapy and cryotherapy.
Reconstruction — Doctors may use Gore-Tex or another substance to reconstruct the diaphragm. Stitches close the chest.
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 P/D
P/D 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 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 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
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.
Who Can Get P/D Surgery?
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 should seek a second opinion. Mesothelioma cases are nuanced and surgical eligibility should be determined by a specialist surgeon.
P/D Eligibility: Stage
Stage of mesothelioma is the most crucial factor for determining eligibility. Cancer staging 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 an option. Stage 1 mesothelioma is contained within the pleura.
In stage 2, there may be tumors in the lungs. Doctors still prefer P/D since peeling the pleura off of the lung can resect the cancer and save the organ.
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 lung out of the body. Others 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 any 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. 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 mortality chances.
Preoperative Patient Evaluation for Mesothelioma P/D
- Age and fitness evaluation
- Blood tests
- Pulmonary function evaluation
- Ventilation/perfusion scan
- Imaging scans
- Echocardiogram
- Stress test
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 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, survival rates for P/D have improved.
In 2008, Dr. Flores led a study resulting in 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 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 With P/D
Mesothelioma treatment continues evolving with time. A new facet is intraoperative therapy, which uses chemotherapy or radiation during radical surgery.
P/D With HITHOC
For intraoperative chemotherapy, doctors apply a hot liquid chemotherapy directly into the cancer site. For pleurectomy with decortication, doctors apply heated intrathoracic chemotherapy (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.
P/D With IORT
Another option is intraoperative radiation therapy (IORT). This method sends radiation beams directly into the chest cavity.
IORT avoids passing through healthy skin and tissue to reach the target. This reduces the damage to healthy tissue or lung scarring.
P/D With IMPRINT
IMPRINT is the acronym for intensity-modulated pleural radiation therapy. One of the aspects of P/D surgery is many doctors feel radiation therapy will damage lung tissue and therefore is not needed.
A study at Memorial Sloan Kettering Cancer Center is testing whether IMPRINT after surgery helps. The data will be split into different categories to help determine how to utilize radiation after P/D surgery:
- Epithelioid cell type versus biphasic cell type
- Completed resection versus incomplete resection
- High-volume centers (more than 10 P/D surgeries per year) versus low-volume centers (10 or fewer P/D surgeries per year)
Possible Pleurectomy With Decortication Complications
As with any surgery, there are risks associated with P/D. The biggest is any long-term side effects from a pleurectomy with decortication.
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. In some cases, P/D surgery isn’t aggressive enough to remove enough tumors. The rate of recurrence decreases for a 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, they can better handle follow-up treatment.
Mortality From Mesothelioma P/D
Some risks may lead to intraoperative or postoperative mortality. In Dr. Flores’ study, the 30-day mortality for P/D was only 1.7%.
Dr. Tsao extraordinarily reported a perioperative mortality rate of 0% among 95 patients. This means none of them died within 30 days after P/D surgery.
Dr. Bueno and Dr. Sugarbaker reported a 30-day mortality rate of 3%. 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 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 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-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 lung-sparing mesothelioma surgery.
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 this cancer. 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.
Frequently Asked Questions About Pleurectomy With Decortication for Mesothelioma
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.
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%.
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.
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.
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
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Costs of medical care for mesothelioma. Rare Tumors. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6637828/. Accessed: 06/23/2021.
