P/D surgery entails removal of diseased pleura and visible tumor in the chest.
While aggressive, it is considered less radical than the other common surgical option, extrapleural pneumonectomy.
P/D surgery can improve prognosis and relieve symptoms for a better quality of life.
A recent study found this treatment provided a median survival of about 36 months.
For some patients with pleural mesothelioma, lung-sparing pleurectomy/decortication (P/D) surgery is an aggressive but effective treatment option that can improve prognosis. This is a surgical procedure that removes the thickened, diseased pleura lining the chest wall (pleurectomy) along with visible tumor on the surface of the lung (decortication). The sac enclosing the heart (the pericardium) and/or diaphragm may also be removed if they are involved with the tumor.
Main Goals of Pleurectomy With Decortication
P/D is one of the two surgical approaches that account for the vast majority of procedures for malignant mesothelioma. The intent of the surgery is to remove as much tumor bulk as possible, which will improve breathing problems and pain caused by the typical thick fibrous bands and adhesions that encase the lung. The procedure will also diminish or eliminate pressure from the excessive fluid that surrounds the lung in the majority of patients. If other parts of the body have been impacted by mesothelioma cells, the surgeon will also remove organs or tissue as necessary, such as the pericardium and diaphragm.
While P/D spares the lung, pleural mesothelioma patients may also be treated with a more radical surgery called extrapleural pneumonectomy (EPP). In contrast, EPP requires the removal of the lung on the cancerous side. There is no clear consensus about which procedure is best, though many experienced mesothelioma surgeons strongly favor one over the other. It is most likely that one is more effective than the other in different settings. Nonetheless, the proportion of patients undergoing P/D compared to EPP has been increasing over the last few decades. This trend is supported by numerous studies in the medical literature, described below.
- As a more extensive surgical procedure, EPP is associated with consistently higher complication and mortality rates compared to P/D.
- For most patients, EPP does not result in sufficiently better results to justify the increased risks. In some settings P/D appears the better choice.
- When anti-cancer drug treatment and/or radiotherapy (multimodal or trimodal therapy) are combined with either procedure, survival is significantly longer than surgery alone.
- Several studies have concluded that patients undergoing P/D are more likely to tolerate these additional treatments with better results.
The Pleurectomy/Decortication Procedure
In most cases, P/D involves removal of the abnormal and constrictive pleura involved with tumor, excision of all visible tumor tissue, and elimination of the accumulated excess fluid. P/D in any form is a major surgical procedure, but unlike EPP, it stops short of complete removal of the lung. The three basic steps are:
The P/D procedure requires inflation of the lung and a rather long incision to provide a sufficiently large opening into the chest cavity to visualize and remove as much abnormal tissue as possible. This incision usually begins in the mid back on the side of the tumor and then follows the rib curvature around to the same side of the chest wall. Often, a rib is removed to increase surgical exposure to the chest cavity.
In the pleurectomy part of the procedure, the diseased pleura lining the inside of the chest cavity (the parietal pleura) is freed from the chest wall.
Then, the tumor-laden visceral pleura is surgically separated and removed from the underlying lung. All other visible tumors are excised and the pericardium and any other similarly abnormal tissue are removed when needed. Separation and removal of these membranes require a lot of time and surgical skill since they often adhere extensively to each other and the surfaces they cover.
Once completed, the incision is closed and at least one tube is inserted into the chest cavity in order to drain any fluids that accumulate thereafter. Since P/D is done under general anesthesia, the patient is unaware of the surgery and does not experience pain during the operation.
Recovery From Pleurectomy With Decortication
Pain following major surgery should be expected, and numerous options to control pain and discomfort are available. At the conclusion of surgery, one or more tubes will emerge from the chest in order to drain any accumulated fluid. During the early recovery period, breathing support may be provided through a tube in the airway that is connected to a respirator. While the tube is in, you will be both unable to speak or ingest fluids. Before hospital discharge, the chest tube(s) will be removed as a bedside procedure that does not require further surgery.
On average, hospitalization lasts 1-2 weeks, followed by an additional 2 – 4 weeks before returning to normal activities.
Success Rates And Complications
Most estimates of mortality associated with P/D range from 1% to 5%; for the more extensive EPP surgery this is usually 2 to 3 times higher. P/D has a good track record for improving or relieving symptoms present before surgery. More than 80% of patients report satisfactory results for chest pain, excess fluid in the chest, cough, and breathing difficulties.
The causes of serious problems following P/D and EPP are essentially the same, but they occur more frequently after EPP. Between 5 – 15% of P/D patients will experience one or more serious complications compared to about 40-60% with EPP.
Complications that are commonly encountered are listed below along with estimates based on medical reports. For comparison, similar estimates are also provided for EPP.
Risk Comparison Between P/D and EPP
|Acute Respiratory Distress Syndrome (severe inflammation and fluid in the lungs)||4% – 15%||4 – 10%|
|Prolonged air leak or leakage of air from lung to chest cavity||10 – 20%||10%|
|Heart arrhythmias||10 – 15%||25 – 45%|
|Reinsertion of breathing tube||2% – 4%||10 – 15%|
|Moderate to severe infections||0 – 5%||4.2%|
Benefits and Life Expectancy
The main benefit of opting for a P/D is improved life expectancy. While the average life expectancy for patients with pleural mesothelioma is around a year with only about 5% of patients surviving for five years, patients who had a P/D experienced improved survival rates. In a study by Dr. Raja Flores, stage 1 mesothelioma patients experienced a survival rate of 40% after five years.
Another benefit of this surgery, which is often referred to as the lung-sparing or lung-saving option, is that the lung is not removed. In an EPP, the lung along with parts of the diaphragm and lining of the heart are also removed where tumors are present.
Dr. Robert Cameron, a known pioneer and leading doctor of P/D, believes “taking out a lung does harm and there is absolutely no benefit to the patient.” Dr. David Sugarbaker, the creator of EPP, believed in both removing visible tumors and whatever is left “at the microscopic level.”
Ultimately, the right option is up to the patient and the advisement of their doctor based on eligibility and individual circumstances.