Trusted Mesothelioma & Lung Cancer Resource Since 2003

Mesothelioma Surgery Options

Surgery offers the best chance for long-term survival when mesothelioma is diagnosed at an early stage. The three primary surgical procedures — extrapleural pneumonectomy (EPP), pleurectomy/decortication (P/D), and CRS+HIPEC for peritoneal mesothelioma — are most effective as part of a multimodal treatment plan that combines surgery with chemotherapy, immunotherapy, and/or radiation.

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Medically reviewed and updated: February 28, 2026 • Sources: NCI, NCCN, ACS

Overview of Mesothelioma Surgery

Surgery is the most aggressive treatment option for mesothelioma and offers the best chance for extended survival when performed on carefully selected patients as part of a comprehensive, multimodal treatment plan. The goal of surgery is to remove as much visible tumor as possible — known as macroscopic complete resection (MCR) — to reduce the disease burden and enhance the effectiveness of subsequent chemotherapy, immunotherapy, and/or radiation therapy.

Not all mesothelioma patients are candidates for surgery. Surgical eligibility depends on the stage of the disease, the histological cell type, the patient's overall health and performance status, and the location of the tumor. Patients diagnosed at Stage I or Stage II with epithelioid or biphasic cell types who are in good general health are the strongest surgical candidates. Surgery is most commonly performed at specialized mesothelioma treatment centers by thoracic surgeons with extensive experience in these complex procedures.

Three primary surgical procedures are used for mesothelioma, each suited to different clinical situations:

Procedure	What Is Removed	Mesothelioma Type	Surgical Mortality	Median Survival
EPP	Lung, pleura, diaphragm, pericardium	Pleural	3–7%	12–22 months
P/D	Pleura, visible tumors (lung preserved)	Pleural	1–4%	14–30 months
CRS+HIPEC	Peritoneal tumors + heated chemo wash	Peritoneal	1–5%	53+ months

P/D Now Preferred Over EPP

MCR Goal: Complete Visible Tumor Removal

Stage I–II Best Candidates for Surgery

53+ Mo. CRS+HIPEC Median Survival

Extrapleural Pneumonectomy (EPP)

Extrapleural pneumonectomy (EPP) is the most radical surgical procedure for pleural mesothelioma. It involves the removal of the entire affected lung, the pleural lining on that side, the diaphragm, and the pericardium (the membrane surrounding the heart). The diaphragm and pericardium are reconstructed using synthetic materials (Gore-Tex patches). EPP was historically considered the standard surgical approach for mesothelioma and was championed by pioneering surgeon Dr. David Sugarbaker.

What EPP Involves

Complete lung removal — the entire lung on the affected side is removed to achieve the widest possible surgical margins
Pleural resection — both the parietal (chest wall) and visceral (lung surface) pleura are removed
Diaphragm reconstruction — the hemidiaphragm on the affected side is removed and replaced with a synthetic prosthesis
Pericardium reconstruction — the portion of the pericardium on the affected side is removed and reconstructed

EPP Outcomes and Considerations

Surgical mortality — 3% to 7% at experienced mesothelioma centers (higher at facilities with less experience)
Hospital stay — typically 7 to 14 days, with extended recovery of 6 to 8 weeks or longer
Median survival — 12 to 22 months, depending on stage, cell type, and completeness of resection
Quality of life impact — loss of one lung permanently reduces respiratory capacity; patients must adapt to single-lung breathing
Complication risk — includes cardiac arrhythmias, respiratory failure, pneumonia, patch failure, bronchopleural fistula, and deep vein thrombosis

EPP vs. P/D: The Evolving Standard

While EPP was historically the procedure of choice, the surgical community has shifted toward pleurectomy/decortication (P/D) as the preferred approach for most patients. The landmark MARS trial (Mesothelioma and Radical Surgery) and subsequent studies suggested that P/D offers comparable or better overall survival with lower surgical mortality and better post-operative quality of life. However, EPP remains appropriate in specific clinical situations where the tumor distribution makes lung preservation impossible.

Medically reviewed and updated: February 28, 2026 • Sources: NCI, NCCN, Annals of Thoracic Surgery

Pleurectomy/Decortication (P/D)

Pleurectomy/decortication (P/D) is a lung-sparing surgical procedure that removes the pleural lining and all visible tumor tissue while preserving the patient's lung. P/D has become the preferred surgical approach for pleural mesothelioma at most major treatment centers because it achieves comparable tumor control to EPP while offering lower surgical mortality, better post-operative lung function, and improved quality of life.

Types of P/D

Extended P/D (eP/D) — the most thorough version; removes the parietal and visceral pleura, all visible tumor, and may include resection of the diaphragm and/or pericardium (which are reconstructed). Extended P/D aims for macroscopic complete resection while preserving the lung.
Standard P/D — removes the parietal pleura and strips tumor from the visceral pleura (decortication) without resecting the diaphragm or pericardium. Appropriate when the disease does not involve these structures.
Partial pleurectomy — a more limited procedure that removes only a portion of the diseased pleura. This is primarily a palliative procedure to control pleural effusion and relieve symptoms, rather than a curative-intent surgery.

P/D Outcomes and Advantages

Surgical mortality — 1% to 4% at experienced centers, significantly lower than EPP
Median survival — 14 to 30 months, depending on stage, cell type, and completeness of cytoreduction
Lung preservation — retaining the lung maintains better respiratory function and exercise tolerance, allowing patients to tolerate subsequent chemotherapy and radiation more effectively
Lower complication rates — fewer cardiac complications, shorter hospital stays (typically 5 to 10 days), and faster recovery compared to EPP
Adjuvant radiation compatibility — the preserved lung can receive intensity-modulated radiation therapy (IMRT) targeting the pleural surfaces with acceptable toxicity

P/D Is Now the Standard at Major Centers

The majority of high-volume mesothelioma treatment centers, including Memorial Sloan Kettering Cancer Center, Baylor College of Medicine, and the University of Pennsylvania, now perform P/D as their primary surgical approach for eligible pleural mesothelioma patients. The combination of lower surgical risk, preserved lung function, and comparable long-term survival has made P/D the surgical standard of care for most patients. Your surgical team will evaluate your specific disease to determine whether P/D or EPP is more appropriate for your situation.

Medically reviewed and updated: February 28, 2026 • Sources: NCI, Journal of Clinical Oncology

CRS+HIPEC for Peritoneal Mesothelioma

Cytoreductive surgery with heated intraperitoneal chemotherapy (CRS+HIPEC) is the standard surgical treatment for peritoneal mesothelioma — the form of mesothelioma that develops in the peritoneum (the lining of the abdominal cavity). CRS+HIPEC combines aggressive surgical tumor removal with the direct application of heated chemotherapy to the abdominal surfaces, achieving results that far exceed systemic chemotherapy alone.

How the Procedure Works

Step 1 — Cytoreductive surgery (CRS) — the surgeon systematically removes all visible tumor tissue from the peritoneal surfaces, including affected portions of the peritoneum, omentum, and any involved organs or tissues. The goal is to achieve complete cytoreduction (CC-0 or CC-1 score), meaning no visible tumor or only microscopic residual disease remains.
Step 2 — Heated intraperitoneal chemotherapy (HIPEC) — after cytoreduction, the abdominal cavity is perfused with heated chemotherapy solution (most commonly cisplatin, at 42–43°C / 107–109°F) for 60 to 90 minutes. The heat enhances the penetration and cytotoxic effect of the chemotherapy, destroying microscopic cancer cells that remain on the peritoneal surfaces after surgery.

CRS+HIPEC Outcomes

Median survival — patients who achieve complete cytoreduction (CC-0) have reported median survival times of 53 months or longer, with some studies reporting 5-year survival rates exceeding 50%
Surgical mortality — 1% to 5% at specialized centers; the procedure is complex and typically lasts 8 to 14 hours
Hospital stay — typically 10 to 14 days, with full recovery taking 8 to 12 weeks
Completeness of cytoreduction — the most important predictor of outcome; patients with complete cytoreduction have significantly longer survival than those with residual visible disease

Best Outcomes at Specialized Centers

CRS+HIPEC is a highly specialized procedure that should only be performed at medical centers with extensive experience in peritoneal surface malignancies. High-volume centers with experienced surgical teams have lower complication rates and better long-term outcomes. If you have been diagnosed with peritoneal mesothelioma, seek evaluation at a center that performs CRS+HIPEC routinely — it is the single most effective treatment available for this disease.

Surgical Candidacy & the Multimodal Approach

Surgery for mesothelioma is most effective when it is one component of a multimodal treatment plan — a coordinated approach that combines surgery with chemotherapy, immunotherapy, and/or radiation therapy. This combined approach destroys cancer at multiple levels: surgery removes visible bulk disease, while systemic therapies target microscopic cancer cells that remain after surgery.

Who Is a Candidate for Surgery?

Stage I or Stage II disease — early-stage patients with localized tumors are the strongest surgical candidates. Select Stage III patients may also qualify.
Epithelioid or biphasic cell type — epithelioid mesothelioma responds best to surgery and carries the most favorable prognosis. Biphasic cases may benefit from surgery depending on the epithelioid-to-sarcomatoid ratio. Purely sarcomatoid mesothelioma is generally not treated with surgery.
Good performance status — patients must be in adequate general health to tolerate a major surgical procedure and the recovery period. Cardiac and pulmonary function tests are required.
Adequate pulmonary reserve — particularly important for EPP, which removes an entire lung. Pulmonary function tests (PFTs) and perfusion studies ensure the remaining lung can sustain adequate oxygenation.
No distant metastases — surgery is intended for localized disease. If the cancer has spread to distant organs (Stage IV), surgery is generally not appropriate, and systemic treatment becomes the primary approach.

Common Multimodal Combinations

Neoadjuvant chemotherapy + surgery + radiation — chemotherapy (pemetrexed + cisplatin) is given first to shrink tumors, followed by surgical resection, then adjuvant radiation to the surgical bed
Surgery + adjuvant chemotherapy — surgery is performed first, followed by systemic chemotherapy to destroy residual microscopic disease
Surgery + immunotherapy — emerging protocols are incorporating immunotherapy (nivolumab + ipilimumab) either before or after surgery in clinical trials
CRS+HIPEC + systemic chemotherapy — for peritoneal mesothelioma, CRS+HIPEC may be followed by systemic chemotherapy to control any residual disease

Seek a Second Opinion at a Specialized Center

If you have been told you are not a candidate for surgery, consider seeking a second opinion at a specialized mesothelioma treatment center. Surgeons at high-volume centers have broader experience and may identify surgical options that are not available at community hospitals. Many patients initially deemed inoperable have gone on to receive successful surgical treatment after evaluation at a specialized center. Your legal rights to compensation are not affected by your treatment decisions.

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FAQ answers reviewed by legal team: February 28, 2026

Frequently Asked Questions About Mesothelioma Surgery

What are the main surgery options for mesothelioma?

The three primary surgical procedures for mesothelioma are: extrapleural pneumonectomy (EPP), which removes the affected lung, pleura, diaphragm, and pericardium; pleurectomy/decortication (P/D), which removes the pleural lining and visible tumors while preserving the lung; and cytoreductive surgery with heated intraperitoneal chemotherapy (CRS+HIPEC), which is the standard surgical approach for peritoneal mesothelioma. P/D has become the preferred approach at most major mesothelioma centers due to lower surgical mortality and better preserved lung function.

Who is a candidate for mesothelioma surgery?

Candidates for mesothelioma surgery are typically patients diagnosed at Stage I or Stage II with epithelioid or biphasic cell type who are in good overall health with adequate heart and lung function. Patients must have no distant metastases and be able to tolerate general anesthesia and a major surgical procedure. A multidisciplinary team at a specialized center evaluates each patient individually. If you have been told you are not a surgical candidate, a second opinion at a high-volume mesothelioma center is recommended.

What is the difference between EPP and P/D surgery?

EPP (extrapleural pneumonectomy) removes the entire affected lung along with the pleura, diaphragm, and pericardium. It has a surgical mortality rate of 3% to 7%. P/D (pleurectomy/decortication) removes the pleural lining and all visible tumors while preserving the lung, with a surgical mortality rate of 1% to 4%. P/D allows patients to retain lung function and has become the preferred surgical approach because studies have shown comparable long-term survival to EPP with fewer complications and better quality of life.

What is CRS+HIPEC for peritoneal mesothelioma?

CRS+HIPEC stands for cytoreductive surgery combined with heated intraperitoneal chemotherapy. It is the standard surgical treatment for peritoneal mesothelioma. The surgeon removes all visible tumors from the abdominal cavity (cytoreduction), then bathes the abdomen with heated chemotherapy (typically cisplatin at 42–43°C) for 60 to 90 minutes to destroy remaining microscopic cancer cells. Patients who achieve complete cytoreduction have reported median survival of 53 months or longer, with some studies reporting 5-year survival rates exceeding 50%.

This page was last reviewed and updated on February 28, 2026 by the legal and medical team at Danziger & De Llano, LLP.

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