The pleurectomy with decortication procedure is for patients with malignant pleural mesothelioma (MPM). This thoracic surgery is mostly for early-stage patients as the cancer has not yet spread.
The Lung-Sparing Mesothelioma Surgery
The pleurectomy with decortication is often called the alternative to the lung-removing extrapleural pneumonectomy (EPP). But the P/D is a surgical treatment that stands on its own in terms of survival benefits. The survival times of people getting EPP and P/D are comparable. Most people increase their survival time by a year or more after these surgeries.
“P/D involves opening the chest and removing all visible tumor,” says Dr. Robert Cameron. “Instead of removing the lung, you carefully separate the tumor from the healthy lung. This can be done very completely so it provides just as much tumor clearance as taking out the lung in an EPP.”
Pleural mesothelioma is not asbestos-caused lung cancer, so it requires different and specialized treatments like a P/D in order to be effectively treated.
Creation of the P/D
Dr. Robert Cameron perfected the modern P/D surgical technique. He works at the West Los Angeles VA Medical Center. He believes the P/D is a more effective treatment of malignant pleural mesothelioma when compared to an EPP.
He points out the survival times as proof that P/D is effective. Patients who have a P/D seem to live a better quality of life over a longer period of time than ever before.
You can discuss this procedure and other available options with the mesothelioma specialist. They can inform you about the pros and cons of surgery that apply to your diagnosis.
Dr. Robert Cameron treats veterans through the Los Angeles VA. He is one of the top mesothelioma surgeons in the world. No matter where you live, veterans with benefits can receive treatment at the Los Angeles VA. It’s one of the only VA cancer centers with a team dedicated to treating mesothelioma.
The Mesothelioma Veterans Center has no affiliation with and is not endorsed or sponsored by Dr. Robert B. Cameron. The contact information above is listed for informational purposes only. You have the right to contact Dr. Cameron directly.
Surgical Steps of the P/D
This is a lung-sparing surgical procedure that involves the removal (resection) of tumors and affected tissue. A surgeon removes the lining of the lung (pleura) but doesn’t remove the lung itself. Unlike the EPP, surgeons don't remove the diaphragm or pericardium. The surgery lasts about five hours.
Pleural mesothelioma patients who have this procedure need to be in fairly good overall health to tolerate it. Doctors do preoperative pulmonary function and cardiac stress tests to make sure the lungs and heart are healthy enough for surgery.
A biopsy will also be performed to make sure the patient has mesothelioma and not another type of cancer.
Historically, patients underwent pleurectomy without decortication. Doctors used it as a palliative surgery meant only to keep the patient more comfortable. With the addition of decortication, many people have extended their survival time.
The pleurectomy with decortication is a 2-step procedure:
- Pleurectomy: Surgeons open the chest cavity while the patient is under general anesthesia. Pleural mesothelioma begins on and in the lining of the lung, which is removed during a P/D. Both the parietal pleural (which covers the thoracic cavity) and the visceral pleura (which covers the lungs) may need to be removed.
- Decortication: Surgeons remove any tumor masses visible inside the lung space. They also remove tumors from the fatty areas between the lobes of the affected lung. If tumors are visible on the diaphragm or pericardium, they are also removed.
There are likely to be mesothelioma cells that aren't visible to the surgeon. Postoperative chemotherapy and radiation can help remove any cancer cells remaining after surgery. Pleurectomy with decortication typically does not cure mesothelioma. However, it may lead to long-term survival or disease remission.
Because the lung is spared, people who have this procedure often recover faster than patients who have an EPP.
Pleurectomy with decortication may be an option for older patients and late-stage patients. Studies suggest that older patients can tolerate this surgery better than the more radical surgery EPP, and for late-stage patients, oncologists (cancer doctors) are experimenting with intraoperative procedures.
One intraoperative method uses strong beams of light to kill mesothelioma in the chest wall. The light is placed in the pleural space during surgery. In one study, patients in stage 3 and 4 had a median survival of 3 years after this treatment option.
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Recovery from Surgery
After the procedure, the patient can still have blood loss and a buildup of fluid around the lungs (pleural effusion).
A chest tube is placed to drain the excess blood and fluid out of the surgical space for a few days. Doctors remove the chest tube when there is no more drainage from this area.
Patients practice deep breathing exercises after surgery, which helps to expand the lungs and prevent pneumonia.
People who have a P/D still need several weeks to recover after leaving the hospital — shorter than the time required to heal from the EPP. Specialists feel the shorter recovery time gives patients a better quality of life following surgery.
Often people have chemotherapy or radiotherapy after the surgery, which further extends the life expectancy of patients in all stages of mesothelioma.
More than 90% of people who undergo the P/D experience a decrease in symptoms after having the procedure.
The mortality rate of this procedure in the days following surgery is about 1-2%, with the biggest complication being a pneumothorax (air leak in the lungs). Bleeding and infection can also occur.
There’s also a risk that an EPP may need to be performed instead of a P/D. Some doctors may have to perform an EPP to give a patient the best chance of survival.
“You never know what you’re gonna find until you get in there at the time of surgery, and at the time of surgery, we will do whatever we need to do to spare that lung. However, there are cases where the lung is so far gone, where they're not getting any function from that lung, and in those particular cases, when necessary, we’ll do an extrapleural pneumonectomy.”
— Dr. Raja Flores, mesothelioma specialist at Mount Sinai Medical Center
The median survival of patients who receive the P/D is about 20 months. This means that half of all people live less than 20 months, and half live longer than 20 months.
Patients live even longer if chemotherapy and radiation are done along with surgery — a multimodality approach. Many cancer cells are left over after surgery, and additional treatments can help get rid of them. Radiation to the original site of mesothelioma, for example, can prevent a recurrence (when the mesothelioma comes back).
In one study done in 2009, people who had all 3 forms of therapy had a median survival rate of around 30 months. That's 10 months longer than the average for P/D surgery alone.
Doctors continue to see if there are ways to increase the benefits of a P/D through clinical trials.
Benefits of a P/D also depend on a patient’s cancer cell type. Mesothelioma tumors can be made up of epithelioid or sarcomatoid cells.
Patients with sarcomatoid mesothelioma often have a lower chance of survival in general. Sarcomatoid cells are less responsive to treatments and can spread past the lung linings, reaching lymph nodes and distant sites like the brain.
Thoracic surgeons can more effectively treat epithelial tumors since they’re less likely to spread.
Some patients may have both eptihelioid and sarcomatoid cells present in their tumors, and these cases are known as biphasic mesothelioma. Biphasic patients respond better to treatments if more epithelioid cells make up the tumor.
Getting a P/D
The pleurectomy with decortication is one of the best treatments for the management of malignant pleural mesothelioma. In recent decades, this procedure has improved significantly. There are reports of patients living up to 7 years after having P/D along with radiation therapy or chemotherapy.
Things to remember about the P/D surgical approach:
- Best for patients in earlier stages.
- Some late-stage patients are eligible for P/D.
- P/D extends overall survival time, sometimes by years.
Patients who have a P/D live longer than those who don’t undergo surgery. If you think this mesothelioma treatment is right for you, talk to your surgeon today. If you are still looking for a specialist, we can help. Read about the top doctors now.