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.

Pleural Mesothelioma Surgery Comparison
Both P/D and EPP surgeries aim to remove mesothelioma tumors to improve survival.

The difference between the two procedures is that EPP carries greater risks and has a larger impact on quality of life. Because this surgery removes an entire lung, it is much more traumatic. Patients who undergo an EPP are more than twice as likely to die during the 30 days after surgery than patients who undergo a P/D. Even after a full recovery, EPP permanently limits the patient’s stamina.

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.

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.

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.

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 itself. There are many factors 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.

P/D vs. EPP Facts
Pleurectomy/Decortication (P/D) Extrapleural Pneumonectomy (EPP)
Less invasive: Removes the lining of the lung and other nearby tissues, but leaves lung intact More invasive: Removes the lung and surrounding tissues, reducing patient’s quality of life
Lower mortality rate: 1–2% of patients die during or immediately after surgery Higher mortality rate: 4–5% of patients die during or immediately after surgery
Less severe complications: May cause prolonged air leak in chest More severe complications: May cause abnormal heart rate or arterial blockage
Source: Annals of Translational Medicine, 2017.

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 judgement 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.

Choosing between the two procedures is complex, but both surgeries can give the patient a good chance to live longer with pleural mesothelioma.