Pleurectomy/Decortication vs. EPP

Patient Advocate Karen Selby explains the pros and cons of EPP and P/D.

Pleurectomy/decortication and extrapleural pneumonectomy are the two most common surgical treatments for pleural mesothelioma. They are both potentially curative, meaning they aim to remove all cancer growth and extend patient life spans. Both surgeries are performed locally in the chest cavity, so they work best on cancer that has not spread to other organs. If the cancer is no longer localized and has spread beyond the lining of the lung, pleurectomy/decortication (P/D) and extrapleural pneumonectomy (EPP) may not be able to remove all cancerous growth.

Despite these similarities, P/D and EPP are vastly different, both in the procedures themselves and in their long-term effects. Some mesothelioma doctors — like Robert Cameron, M.D. — prefer to perform P/D, while others — like David Sugarbaker, M.D. — believe EPP is more advantageous. In most cases, a patient's doctors and surgeons, along with the patient, decide which surgery is best for that particular case.

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Comparing and Contrasting Pleurectomy/Decortication and Extrapleural Pneumonectomy

Although the goal of both surgeries is to extend lifespan, EPP and P/D have different potential effects on a patient, with each procedure having its own set of advantages and disadvantages. EPP has a large effect on quality of life: This surgery removes an entire lung, permanently limiting physical activity. But in return, the surgery is more likely to remove the entire tumor, taking out cancer growth on the lung itself that P/D may have left behind. P/D removes only the lining of the lung and leaves the actual lung intact, making it the less drastic option. Although it is more likely to leave tumor growth in the chest cavity, P/D is associated with a better quality of life and fewer surgical complications.

In general, both P/D and EPP have been found to improve survival times in pleural mesothelioma patients, with studies finding mean survival times of nine to 19 months after either surgery. This is an improvement from typical survival times of four months to a year when patients receive only symptom-reducing care rather than potentially curative treatment such as P/D or EPP. Below is a summary of how the two surgeries vary.

Comparing and Contrasting PD and EPP

Pleurectomy/Decortication Extrapleural Pneumonectomy
Potentially curative Potentially curative
Removes only the lining of the lung, leaving the lung intact Removes the entire lung, negatively affecting quality of life
Median survival time: 9-19 months Median survival time: 9-19 months
Lower mortality rate: 4% die during or immediately after surgery Higher mortality rate: 7% die during or immediately after surgery
6.4% of patients experience severe respiratory problems 10% of patients experience severe respiratory problems
More likely to leave behind local cancer cells: two-thirds of patients have local recurrences More likely to remove all local cancer cells: one-third of patients have local recurrences

Survival Rates

In clinical studies, P/D and EPP both lead to longer median survival rates. One retrospective study reviewed the cases of 663 pleural mesothelioma patients treated with EPP or P/D between 1990 and 2006. It found that patients who underwent P/D had longer median survivals than those who underwent EPP: 16 months versus 12 months, respectively.

Survival By Prodedure Graph

A 2008 study found that pleural mesothelioma patients who undergo pleurectomy/decortication live longer than those who undergo extrapleural pneumonectomy. Source: http://www.ncbi.nlm.nih.gov/pubmed/18329481

However, the study's researchers note that this does not necessarily mean P/D leads to longer survival times. The outcomes were skewed by differences in other prognostic factors such as histological type of mesothelioma, stage of the cancer and median age of patients. Researchers concluded that one surgical option is not definitively better than the other, and that the choice of treatment should be made on a case-by-case basis.

Combining EPP or P/D with Other Treatments

Another recent study of 139 pleural mesothelioma patients also found that pleurectomy/decortication and extrapleural pneumonectomy lead to similar survival rates. Patients in the study who received EPP lived a median of 10.3 months, and patients who received P/D lived a median of 10.1 months.

Post Operative Survival Graph

A 2009 study found that combining extrapleural pneumonectomy or pleurectomy/decortication with other treatments led to longer survival times in pleural mesothelioma patients.

When the groups were broken down by whether patients received further treatments, survival rates were more distinct. Patients who underwent P/D alone lived slightly longer than patients who received EPP alone. Both surgeries showed better survival times when they were combined with chemotherapy and/or radiation therapy in a multimodal approach. Patients who received P/D, chemotherapy and radiation therapy lived longest, achieving a median survival of 26 months.

Deciding Which Surgery is Right

Ultimately, a patient's doctor or surgeon will steer the patient towards the right surgery for his or her particular situation. For any invasive surgery, the patient must be in good overall health so that he or she is able to properly recover from surgery. If the patient is a candidate for surgery, the doctor will consider the size and location of the tumor. If the tumor is localized to the pleura, 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.

When choosing between EPP and P/D, the doctor will also consider the patient's specific medical needs and preferences, along with which operation the surgeon is more comfortable performing. Choosing between the two procedures may be difficult, but the patient is likely to live longer after undergoing either surgery.

Additional Resources

  1. Brigham and Women's Hospital (2010). David J. Sugarbaker, M.D. Retrieved from http://www.chestsurg.org/about/staff/
  2. Flores, R.M. et al (2008). Extrapleural pneumonectomy versus pleurectomy/decortication in the surgical management of malignant pleural mesothelioma: Results in 663 patients. The Journal of Thoracic and Cardiovascular Surgery, 135, pp. 620-626. Retrieved from http://www.jtcvsonline.org/home
  3. Luckraz, H. et al (2009). Three decades of experience in the surgical multi-modality management of pleural mesothelioma. European Journal of Cardio-thoracic Surgery, 37, pp. 552-556. Retrieved from http://ejcts.oxfordjournals.org/
  4. Mineo, T.C., Ambrogi, V. & Pompeo, E. (2008). "Surgical Management of Malignant Pleural Mesothelioma." In A. Baldi (Ed.), Mesothelioma from Bench Side to Clinic (pp. 413-434). New York: Nova Science Publishers, Inc.
  5. Pacific Meso Center (2011). Dr. Robert Cameron on Treating Mesothelioma: Debunking the Myths about P/D. Retrieved from http://www.phlbi.org/divisions/lung-disease/pacific-meso-center/sfor-patients/debunking-the-myths-about-pd/

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