Pleurectomy Decortication (P/D) vs. Extrapleural Pneumonectomy (EPP)

Differences Between P/D and EPP Surgeries

The goal of pleurectomy/decortication (P/D) and extrapleural pneumonectomy (EPP) is to remove all pleural mesothelioma cancer growth, relieve symptoms and extend the patient’s life span. Because both surgeries are performed locally in the chest cavity, they work best when the cancer has been found as early as possible and not spread outside of the chest cavity.

If the mesothelioma has advanced to a late stage and is no longer localized, neither procedure may provide significant benefit for the patient. In addition, a patient must be in good overall health to survive and recover from any major chest surgery. Otherwise, it cannot safely be offered even in early-stage cases.

P/D may involve scraping cancer cells off the surface of a lung, but it leaves both lungs intact. Most thoracic surgeons now prefer the P/D procedure for this reason, but they will still perform an EPP if they determine it is the only way to remove as much tumor growth as possible.

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Survival Rates

Both P/D and EPP improve survival rates for pleural mesothelioma patients, especially when combined with other treatments as part of multimodal therapy. In a 2022 study, mesothelioma patients who underwent EPP had a median overall survival of 15 months versus 22 months for those who underwent pleurectomy and decortication surgery.

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Dr. Jeffrey Velotta: Pleurectomy/Decortication vs Extrapleural Pneumonectomy

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I would say there are some instances where we still have to do an extrapleural pneumonectomy where we take out the lung. The main difference is though, and that’s probably very less common, The main difference with a pleurectomy decortication versus extra pleural pneumonectomy is that the nice thing about the pleurectomy decortication is that you’re just removing the lining. I feel that really a pleurotomy and decortation should always be on the patient’s mind first and really should be on the surgeon’s mind first. And that, yes, sometimes, every once in a while, one percent of the time or five percent of the time, we have a bailout where, hey, this long It’s just so infiltrated with mesothelioma and we take off the peeling, the lining, the mesothelioma and we see the lung and every once in a while, like I said, one in the last five years, the lung is just totally not functional anymore.

In that case, again, is the nuances, right? These are nuances that people don’t talk to you about. That case, you do wanna remove the lung because if you do leave the lung in and it’s already pretty much not a functional lung, that can actually do worse because you may have to go back in and take out, go for a second operation because that lung just was too foregone with compression of the mesothelioma. So I think that’s kind of the nuance with it, but bottom line is what we should be all telling patients and advocating for is a pleurectomy and decortication.

Some studies have associated P/D with longer survival times than EPP, but this does not necessarily mean the survival advantage comes from the procedure. Many factors are associated with survival including the cancer stage and indications to select one procedure versus the other.

The cancer stage and cell type, the patient’s age and the types of adjuvant therapies used all affect survival times much more than the type of surgery performed.

Deciding Which Surgery Is Right

When choosing between EPP and P/D, the surgeon will consider the patient’s specific medical needs and preferences. Many thoracic surgeons are more comfortable with one procedure than the other, so the patient’s choice of cancer center and mesothelioma specialist may influence the type of surgery they receive.

If the patient is a candidate for surgery, the surgeon will consider the size and location of the tumor. If the tumor is localized to the pleural lining, P/D may suffice, but if the tumor has spread to the lung, EPP may be necessary to remove a greater portion of the tumor.

Mesothelioma specialists can use a variety of imaging scans to try to assess the extent of the cancer’s spread, but in many cases, a surgeon will not make the final judgment call until they have opened the patient’s chest cavity during surgery and seen the extent of the tumor growth directly. A surgeon may begin surgery intending to perform P/D but then realize an EPP would be better, or the other way around.

We’re finding that we’re able to remove all the tumor that’s visible even with the lung-sparing pleurectomy/decortication. That is why there has been a shift toward doing [P/D] more so than in decades past.

Dr. Andrea Wolf, director of the New York Mesothelioma Program at Mount Sinai

Choosing between the two procedures is complex, but both surgeries can give the patient a good chance to live longer with pleural mesothelioma. A mesothelioma specialist is the best doctor to help a patient and their loves ones make the decision between an EPP or the P/D surgeries.