Pleurectomy/decortication (P/D) is a two-part procedure. The pleurectomy involves opening the chest cavity and removing the pleural lining around the lungs as well as other diseased tissues. The decortication then removes any visible tumor masses from the surface of the lung and the rest of the chest area.
- Success Rate: 90 percent of patients experience reduced symptoms.
- Mortality Rate: 1 to 2 percent of patients die during or immediately after P/D.
- Complications: 1 in 10 patients suffer a prolonged air leak, the most common complication.
- Survival Time: Median survival is about 20 months, depending on other prognostic factors.
In the past, pleurectomy was commonly performed as a palliative measure for pleural mesothelioma patients to reduce the buildup of fluid around a lung and alleviate pain, but ever since surgical advancements made decortication possible, mesothelioma specialists almost always combine the two procedures. This highly detailed procedure takes several hours to complete, and its success depends on the skill of experienced thoracic surgeons.
To qualify for major surgery, mesothelioma patients must usually be in good overall health with an early stage of pleural mesothelioma. Pleurectomy/decortication can extend survival and increase quality of life significantly for eligible patients, especially when part of a multimodal treatment approach including chemotherapy, radiation therapy, immunotherapy or other emerging treatment technologies.
Though thoracic surgeons have increasingly come to prefer P/D over the older and more invasive extrapleural pneumonectomy (EPP) procedure, in many cases surgeons will decide which procedure to perform only after they have already started surgery and evaluated the extent of the cancer growth firsthand.
For the procedure, the patient is positioned on their side to give the surgeon the most direct access to the chest cavity.
The surgeon begins by making a long incision called a thoracotomy. The cut starts on the back, near the sixth or seventh rib from the top, and it continues down the chest, parallel to the spine, then curves outward to extend parallel to the ribs. If the tumor extends lower in the chest cavity, a second incision may be made near the eighth or ninth rib.
Once the surgeon has access to the chest cavity, they remove the parietal pleura, which is the outside layer of the pleural lining. The lung itself is left intact, but the surgeon may also remove parts of the chest wall lining, heart sac and diaphragm.
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After finishing the pleurectomy, the surgeon removes any visible tumor growth in the chest area. While the chest cavity is exposed, specialists pack the area with hot gauze and use other methods to minimize blood loss.
The surgeon may scrape the affected lung to remove the maximum possible amount of cancer tissue. Some specialists have also integrated an experimental targeted treatment called photodynamic therapy into this procedure, which has shown promising results.
Once the decortication is complete, the surgeon stitches the incision closed.
Recovery After P/D Surgery
In the days following P/D surgery, the chest wall might continue to lose small amounts of blood, and air leaks may occur in the area. During a hospital stay of about one week, doctors monitor the patient’s recovery closely and may have them practice deep-breathing exercises.
After the patient is discharged from the hospital, total recovery usually takes several more weeks. Patients still struggling with mesothelioma symptoms after recovery may be eligible for complementary treatments, such as pulmonary rehabilitation, to further ease breathing and lessen symptoms.
Studies show the longest survival times after P/D are associated with a multimodal approach involving other types of treatments. Postoperative chemotherapy, radiation therapy or immunotherapy can kill cancer cells that were left behind during surgery, and many treatment plans include multiple adjuvant therapies to try to prevent cancer reoccurrence as long as possible.
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Dr. Robert Cameron’s Pioneering Work
Thoracic surgeon Dr. Robert Cameron, a mesothelioma specialist from the UCLA Medical Center, pioneered the P/D surgery more than 20 years ago. He is the driving force behind the Pacific Mesothelioma Center and has campaigned to make P/D the standard of care for early-stage pleural mesothelioma.
Dr. Cameron believes one day pleural mesothelioma will be effectively treated as a chronic illness, with repeated P/D procedures extending a patient’s life years at a time.
Since the advent of P/D, specialists have debated whether it is as effective as extrapleural pneumonectomy (EPP), which involves removing the pleural lining and the affected lung.
The advantage of P/D is that it leaves the patient with both their lungs, whereas EPP permanently reduces a patient’s stamina. Proponents of EPP, on the other hand, have argued that because P/D is less invasive, it has a lower chance of successfully eliminating cancer from the body.
However, research studies show EPP and P/D lead to similar survival rates. Because P/D is associated with fewer complications and better quality of life, most mesothelioma specialists today agree P/D is preferable in cases where cancer tissue has not invaded the lung.
8 Cited Article Sources
- Mineo, T.C., Ambrogi, V., & Pompeo, E. (2008) "Surgical Management of Malignant Pleural Mesothelioma." In A. Baldi (Ed.), Mesothelioma from Bench Side to Clinic (413-434). New York: Nova Science Publishers, Inc.
- Neragi-Miandoab, S., Richards, & W.G., Sugarbaker, D.J. (2008). Morbidity, mortality, mean survival, and the impact of histology on survival after pleurectomy in 64 patients with malignant pleural mesothelioma. International Journal of Surgery, 6(4), 293-297. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/18585112
- Pacific Meso Center. Dr. Robert Cameron on Treating Mesothelioma -- Debunking the Myths about P/D. (2011). Retrieved from: http://www.phlbi.org/
- Pass, H.I., MD, Metula, A., BSN, RN, MA, ANP-C, & Vento, S. (2010). 100 Questions and Answers about Mesothelioma. Sudbury, Mass.: Jones & Bartlett Publishers.
- Roberts, J.R. (1999). Surgical Treatment of Mesothelioma: Pleurectomy. Chest (116, 446S-449S). Retrieved from: http://journal.chestnet.org/article/S0012-3692(15)30742-X/fulltext
- Friedberg, J.S. et al. (2017, March). Extended Pleurectomy-Decortication–Based Treatment for Advanced Stage Epithelial Mesothelioma Yielding a Median Survival of Nearly Three Years. Retrieved from: http://www.annalsthoracicsurgery.org/article/S0003-4975(16)31139-0/fulltext
- Schwartz, R.M. et al. (2017, June). The impact of surgical approach on quality of life for pleural malignant mesothelioma. Retrieved from: http://atm.amegroups.com/article/view/13976/html
- Taioli, E., Wolf, A.S., and Flores, R.M. (2015, February). Meta-Analysis of Survival After Pleurectomy Decortication Versus Extrapleural Pneumonectomy in Mesothelioma. Retrieved from: http://www.annalsthoracicsurgery.org/article/S0003-4975(14)01926-2/fulltext
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Last Modified September 25, 2018