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Pleurectomy Decortication vs. EPP

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Pleurectomy/decortication (P/D) and extrapleural pneumonectomy (EPP) are the two most common tumor-removing surgeries for pleural mesothelioma. P/D is associated with fewer complications and better quality of life, but surgeons may choose the more drastic EPP if cancer has spread into the lung.

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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.

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.

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.

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. Rather, patients selected for P/D are usually healthier to begin with than patients who undergo EPP, so it is difficult to make a direct comparison.

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.

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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.

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Registered Nurse and Patient Advocate

Karen Selby joined in 2009. She is a registered nurse with a background in oncology and thoracic surgery and was the regional director of a tissue bank before becoming a Patient Advocate at The Mesothelioma Center. Karen has assisted surgeons with thoracic surgeries such as lung resections, lung transplants, pneumonectomies, pleurectomies and wedge resections. She is also a member of the Academy of Oncology Nurse & Patient Navigators.

Walter Pacheco, Managing Editor at
Edited by
Dr. Daniel Landau, mesothelioma specialist & medical content reviewer for
Medical Review By

7 Cited Article Sources

The sources on all content featured in The Mesothelioma Center at include medical and scientific studies, peer-reviewed studies and other research documents from reputable organizations.

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  4. Pacific Meso Center. (2011). Dr. Robert Cameron on Treating Mesothelioma: Debunking the Myths about P/D.
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Last Modified August 27, 2020

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