Pleurectomy/Decortication (P/D)

Pleurectomy/decortication (P/D) is a lung-sparing cytoreductive surgery for malignant pleural mesothelioma that removes the diseased pleura and all visible tumor while preserving the underlying lung. Unlike extrapleural pneumonectomy (EPP), which removes the entire affected lung, P/D allows patients to retain bilateral lung function, resulting in better postoperative quality of life, lower surgical mortality, and fewer major complications. P/D has become the preferred surgical approach at most mesothelioma centers worldwide.¹

The procedure involves stripping the parietal pleura from the chest wall and the visceral pleura from the lung surface (decortication), along with resection of all macroscopically visible tumor deposits. In its extended form — extended pleurectomy/decortication (EPD) — the ipsilateral pericardium and hemidiaphragm are also resected and reconstructed with prosthetic mesh, similar to EPP but without lung removal. Extended P/D achieves comparable tumor debulking to EPP while preserving the lung parenchyma.²

Multiple retrospective studies and institutional series have reported that P/D achieves similar or superior overall survival compared to EPP, with significantly lower perioperative mortality (1–4% vs. 3–7%) and morbidity. A large multi-institutional analysis published in the Journal of Thoracic and Cardiovascular Surgery demonstrated median survival of 16 to 20 months after P/D, comparable to EPP outcomes. The survival equivalence, combined with lower surgical risk and better postoperative lung function, has driven the shift toward P/D as the standard cytoreductive approach.³

Like EPP, P/D is most effective as part of a multimodal treatment plan that includes systemic chemotherapy (typically pemetrexed plus cisplatin or carboplatin) and, in some protocols, radiation therapy. Patient selection remains critical — the best outcomes are achieved in patients with epithelioid histology, early-stage disease, and good performance status who are treated at high-volume centers with experienced thoracic surgical teams.⁴

P/D exists on a spectrum of surgical aggressiveness:²

• Standard P/D — Removes the parietal and visceral pleura with visible tumor debulking. Pericardium and diaphragm are preserved. Appropriate when tumor is limited to the pleural surfaces.²
• Extended P/D (EPD) — Also resects and reconstructs the pericardium and hemidiaphragm. Achieves the same resection extent as EPP while preserving the lung. The most common form at major centers.²
• Palliative partial pleurectomy — Less extensive; performed to control recurrent effusions and improve symptoms rather than achieve macroscopic complete resection.¹

As a treatment procedure, P/D does not cause symptoms. The symptoms that may lead a physician to recommend P/D include:¹

• Dyspnea from trapped lung or large pleural effusions
• Chest pain from tumor involvement of the chest wall or intercostal nerves
• Cough that does not respond to medical therapy
• Recurrent pleural effusions requiring repeated thoracentesis
• Weight loss and declining functional status

Postoperative symptoms after P/D are generally less severe than after EPP because both lungs are preserved. Patients may experience surgical site pain, temporary shortness of breath, and reduced exercise tolerance during recovery, but pulmonary function typically recovers to near-baseline levels within 3 to 6 months.³

P/D is a treatment procedure, not a diagnostic one. Preoperative evaluation for P/D candidacy includes:⁴

• Histological confirmation — Tissue biopsy confirming mesothelioma is required. Thoracoscopy (VATS) provides both diagnostic tissue and direct assessment of tumor distribution on the pleural surfaces, which helps surgical planning.¹
• CT and PET-CT imaging — Determine tumor extent, chest wall invasion, nodal involvement, and distant metastases. Imaging helps surgeons plan the extent of resection and decide between standard P/D and extended P/D.⁴
• Pulmonary function testing — While P/D preserves the lung, adequate baseline pulmonary function is still needed to tolerate thoracotomy and the postoperative recovery period. P/D has less stringent pulmonary function requirements than EPP.³
• Cardiac evaluation — Standard preoperative cardiac assessment, particularly if extended P/D with pericardial resection is planned.⁴
• Performance status — Patients should have adequate functional status (ECOG 0–2) to withstand major thoracic surgery. P/D can be offered to a broader range of patients than EPP due to its lower physiological demands.⁴

P/D may be considered across a wider range of mesothelioma stages than EPP:²

• Stage I — Ideal candidates. P/D can achieve macroscopic complete resection with minimal morbidity.²
• Stage II — P/D remains effective, with extended P/D performed when the diaphragm or pericardium is involved.²
• Stage III — P/D may still be offered for selected stage III patients, particularly those with limited chest wall invasion and ipsilateral nodal involvement. Macroscopic complete resection may be more difficult to achieve.²
• Stage IV — P/D is generally not indicated for curative intent, though palliative partial pleurectomy may be performed for symptom control.¹

P/D is itself a treatment. Through a posterolateral thoracotomy, the surgeon dissects the parietal pleura from the chest wall, strips the visceral pleura and tumor from the lung surface (decortication), and resects the pericardium and diaphragm if involved (extended P/D), reconstructing with prosthetic mesh. Mediastinal lymph nodes are sampled. Operative time is 3 to 5 hours with a hospital stay of 5 to 10 days.²

Multimodal approaches:

• Neoadjuvant chemotherapy + P/D — 3–4 cycles of pemetrexed/cisplatin before surgery to reduce tumor burden and assess treatment response. Patients who respond well to chemotherapy are more likely to benefit from surgery.⁴
• P/D + adjuvant chemotherapy — Surgery followed by systemic chemotherapy to treat microscopic residual disease.⁴
• P/D + HITHOC — Hyperthermic intrathoracic chemotherapy — heated chemotherapy lavage applied directly to the chest cavity after tumor resection, targeting microscopic residual tumor cells on tissue surfaces.⁴
• P/D + immunotherapy — Emerging protocols combine P/D with checkpoint inhibitors (nivolumab, ipilimumab, pembrolizumab) as adjuvant or neoadjuvant therapy.¹

Complications (less frequent and less severe than EPP):

• Operative mortality: 1–4% at experienced centers
• Major morbidity: 15–30%, including prolonged air leak (most common), atrial fibrillation, pneumonia, and empyema
• Prolonged air leak is more common after P/D than EPP because the decorticated lung surface may have small parenchymal injuries

Median survival after P/D ranges from 14 to 22 months, comparable to EPP. Institutional series report median survival exceeding 24 months in patients with epithelioid histology, macroscopic complete resection, and early-stage disease. Five-year survival rates range from 10–18% in favorable-risk patients.³

A meta-analysis comparing P/D and EPP found no significant difference in overall survival, but P/D had significantly lower operative mortality (odds ratio 0.49). The primary concern with P/D is higher local recurrence rates — because the lung is preserved, microscopic tumor cells may remain on its surface — but this has not translated into inferior overall survival.³

Quality of life after P/D is significantly better than after EPP. P/D patients recover pulmonary function more quickly, maintain higher exercise capacity, and report better overall well-being. This quality-of-life advantage — combined with equivalent survival — makes P/D the preferred surgical option at most centers.⁴

Recovery and life after P/D are generally more favorable than after EPP because both lungs are preserved:⁴

• Pulmonary function recovery — Most patients recover to 70–90% of their preoperative lung function within 3 to 6 months after P/D, compared to the permanent 50% reduction after EPP
• Physical activity — Patients can typically resume normal daily activities within 4 to 6 weeks and may return to moderate exercise within 2 to 3 months
• Follow-up monitoring — CT scans every 3 to 4 months for the first 2 years, then every 6 months, to monitor for local recurrence
• Ongoing multimodal therapy — Adjuvant chemotherapy or immunotherapy may continue after surgical recovery
• Support services — Pulmonary rehabilitation, nutritional counseling, psychological support, and connection with mesothelioma patient support groups are important components of post-surgical care