EPP vs. Pleurectomy/Decortication (P/D) for Mesothelioma
Extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D) are the two primary surgical approaches for treating pleural mesothelioma. EPP is the more radical procedure, removing the entire affected lung along with the pleural lining, diaphragm, and pericardium. P/D is a lung-sparing approach that removes the diseased pleura and visible tumor while preserving the underlying lung. Over the past decade, clinical trends have shifted toward P/D as the preferred option at most major treatment centers, though EPP remains appropriate for select patients.
| Factor | Extrapleural Pneumonectomy (EPP) | Pleurectomy/Decortication (P/D) |
|---|---|---|
| What's removed | Affected lung, visceral and parietal pleura, ipsilateral diaphragm, and pericardium | Visceral and parietal pleura and all visible tumor; lung is preserved |
| Goal of surgery | Macroscopic complete resection (MCR) — remove all visible disease by removing the entire lung and surrounding structures | Macroscopic complete resection (MCR) — remove all visible disease while preserving lung function |
| Typical candidate | Younger patients (under 70) with good cardiopulmonary function, epithelioid cell type, early-stage disease | Broader eligibility; patients who may not tolerate lung removal, older patients, or those with comorbidities |
| Hospital stay | 10–14 days on average | 7–10 days on average |
| Recovery time | 6–8 weeks; significant adjustment to single-lung function | 4–6 weeks; preserved lung allows faster functional recovery |
| Operative mortality rate | 3.4–7% at high-volume centers (historically higher at low-volume centers) | 1.5–4% at high-volume centers |
| Median survival | 12–22 months (up to 29 months in select epithelioid patients with multimodal therapy) | 14–26 months (up to 30+ months in select epithelioid patients with multimodal therapy) |
| Lung preservation | No — the entire affected lung is removed | Yes — the lung is preserved, maintaining bilateral breathing capacity |
| Quality of life impact | Greater reduction in respiratory capacity; permanent loss of one lung affects exercise tolerance and daily activities | Better preserved respiratory function; patients generally report higher quality of life scores post-surgery |
| Eligibility for adjuvant therapy | Patients may receive chemotherapy and/or radiation after surgery; intensity-modulated radiation therapy (IMRT) to the hemithorax is possible without risk to remaining lung | Patients receive chemotherapy and/or radiation; radiation must be more carefully targeted to protect the preserved lung |
| When first developed | Pioneered in the 1970s–1980s; refined by Dr. David Sugarbaker at Brigham and Women's Hospital | Developed in the 1990s–2000s; increasingly refined with improved surgical techniques |
Sources: Sugarbaker et al. (Annals of Thoracic Surgery), Flores et al. (Journal of Thoracic and Cardiovascular Surgery), MARS Trial (Lancet Oncology), NCCN Clinical Practice Guidelines
Surgical decisions are deeply personal
The choice between EPP and P/D depends on your specific tumor characteristics, stage, cell type, overall health, and the expertise available at your treatment center. This comparison provides context — your thoracic surgeon and oncology team will recommend the best approach for your situation.
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Key Differences
Surgical Scope
The most significant difference is what gets removed. EPP is among the most extensive thoracic surgeries performed — it removes not only the pleural lining but the entire lung, the diaphragm on the affected side, and often part of the pericardium. These structures are then reconstructed with synthetic patches. P/D takes a more conservative approach, meticulously peeling the diseased pleura away from the lung and removing all visible tumor while leaving the lung intact. Extended P/D may also include removal of the diaphragm and pericardium if tumor has invaded these structures, blurring the line between the two procedures in some cases.
Recovery and Quality of Life
P/D patients consistently report better post-operative quality of life, primarily because they retain both lungs. This means better exercise tolerance, less shortness of breath, and a faster return to daily activities. A 2015 study published in the Journal of Thoracic Oncology found that P/D patients had significantly higher forced vital capacity (FVC) scores at 6 months compared to EPP patients. The shorter hospital stay and lower complication rate associated with P/D also contribute to a smoother recovery period. For older patients and those with pre-existing heart or lung conditions, this difference can be decisive in determining which surgery is appropriate.
Survival Outcomes
Comparing survival between EPP and P/D is complicated because the procedures tend to be performed on different patient populations. The MARS trial (Mesothelioma and Radical Surgery), published in Lancet Oncology in 2011, raised concerns about EPP when it found no survival benefit over P/D and higher perioperative mortality. However, this trial was criticized for its small sample size and methodology. Subsequent large institutional series from high-volume centers have shown comparable long-term survival for both procedures when performed by experienced surgeons as part of a multimodal treatment plan. The key factor in survival appears to be achieving macroscopic complete resection (MCR) regardless of which technique is used.
Current Clinical Trends
Over the past decade, the mesothelioma surgical community has shifted significantly toward P/D as the preferred approach. The NCCN Guidelines now list P/D as the recommended surgical approach, with EPP reserved for select cases. Major mesothelioma centers including Memorial Sloan Kettering, MD Anderson, and Brigham and Women's Hospital have increasingly favored P/D. This trend reflects accumulating evidence that P/D achieves similar oncologic outcomes with lower morbidity, and that the lung-sparing approach allows patients to better tolerate subsequent chemotherapy and immunotherapy. However, some surgeons continue to advocate for EPP in specific clinical scenarios — particularly for younger patients with early-stage epithelioid tumors where the goal is maximum cytoreduction.
Which Is Right for You?
This decision should be made in close consultation with a thoracic surgeon who has significant experience with mesothelioma. The optimal choice depends on multiple interrelated factors specific to your case.
- P/D may be recommended if: you want to preserve lung function, you are older or have comorbidities that increase surgical risk, you have early-to-mid stage disease where tumor can be adequately removed while sparing the lung, or your treatment plan includes post-operative therapies that benefit from preserved respiratory capacity.
- EPP may be recommended if: you are younger with excellent cardiopulmonary function, your tumor involves extensive pleural thickening that cannot be adequately resected with P/D, your surgeon believes MCR is better achieved with lung removal, or your treatment plan includes hemithoracic radiation that is easier to deliver safely without the ipsilateral lung.
The most important factor is the experience and judgment of your surgical team. Patients treated at high-volume mesothelioma centers have significantly better outcomes regardless of which procedure is performed, because these centers have the specialized expertise, multidisciplinary teams, and post-operative care protocols that complex mesothelioma surgery demands.
- Sugarbaker DJ, et al. "Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma." Journal of Thoracic and Cardiovascular Surgery, 1999
- Flores RM, et al. "Extrapleural pneumonectomy versus pleurectomy/decortication in the surgical management of malignant pleural mesothelioma: Results in 663 patients." Journal of Thoracic and Cardiovascular Surgery, 2008
- Treasure T, et al. "Extra-pleural pneumonectomy versus no extra-pleural pneumonectomy for patients with malignant pleural mesothelioma: clinical outcomes of the Mesothelioma and Radical Surgery (MARS) randomised feasibility study." Lancet Oncology, 2011
- NCCN Clinical Practice Guidelines in Oncology: Malignant Pleural Mesothelioma (Version 1.2026)
- Annals of Thoracic Surgery, institutional outcome series from major mesothelioma treatment centers, 2018–2025
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