Surgery Treatment in Malignant Pleural Mesothelioma

Mesothelioma Surgery is a viable option for some patients. Usually, it is recommended for patients who are healthy enough for surgery and whose mesothelioma has not spread too far. Mesothelioma Surgery is particularly effective in patients when coupled with other treatments such as chemotherapy or radiation or immunotherapy.

There are two surgical procedures which are used for treating mesothelioma: the Extra Pleural Pneumonectomy (EPP) and the Pleurectomy with Decortication (P/D)

What is the Extra Pleural Pneumonectomy?

The Extra pleural Pneumonectomy, or “EPP”, is a radical procedure which involves the surgical removal of the entire lung, a portion of the diaphragm (the muscle located below the lung) and the pericardium (the lining of the heart). Because of the radical nature of this procedure, and the fact that the patient will be left post-operatively with only one lung, it can only be performed on patients who meet certain criteria such as good cardiac and pulmonary functioning.

There are five major steps in the EPP procedure, including:

  • Making an incision to expose the parietal pleura
  • Separating the parietal pleura from the fascia, diaphragm, and mediastinum
  • Dividing up the pulmonary vessels, subcarinal node dissection, staple main stem bronchus
  • Piecing back together the lung, lung covering, pericardium and diaphragm
  • Reconstruction surgery for the diaphragm and pericardium

What is the Pleurectomy with Decortication?

The Pleurectomy with Decortication, or “P/D” is a procedure which involves just removing the affected pleura, not the lung. This releases the lungs so that they can expand and contract normally again.

The P/D procedure effectively peels away the layer of abnormal fibers from the lung. By peeling away the layer of fibers that are trapping the lung, the patient’s lungs are free to fill the entire pleural space again, thus relieving the patient’s symptoms (difficulty breathing, etc.)

There are five major steps in the P/D procedure, including:

  • Making an incision to expose the parietal pleura
  • Separating the parietal pleura from surrounding tissue (fascia, diaphragm, mediastinum)
  • Cutting the parietal pleural open to reveal the visceral pleura
  • Peeling away – “Decortation” – of the visceral pleura
  • Reconstruction

EPP vs P/D

In 2021 MD Anderson Cancer Center conducted a retrospective study comparing surgical outcomes and long-term survival of mesothelioma patients who underwent either the extra-pleural pneumonectomy (EPP) or the pleurectomy/decortication (P/D) over the last two decades.

Although the study concluded that both the EPP and P/D had comparable long term oncological outcomes, it found that the P/D was better tolerated and had much lower perioperative mortality rates. The EPP was formally the surgery of choice until patients started choosing the P/D more in recent years.

  • The P/D takes longer to perform but less radical than the EPP.
  • The P/D has a much lower rate of surgical mortality and can be performed on patients who would not be eligible for EPP

Despite the benefits of P/D vs. EPP, EPP has been the most frequently used surgery for mesothelioma. However, as more information has been published regarding reduced surgical mortality, enhanced post-surgery quality of life and comparable if not better survival with P/D, more and more surgeons are recommending P/D over EPP However, because of the complexity of the P/D, it is important to choose a surgeon with substantial experience performing the procedure.

Of course, you want an honest and qualified assessment of your best options for long-term survival of MPM. Who is qualified to answer your questions?

The Pacific Meso Center:

  1. Mesothelioma
    Can answer all your questions.
  2. Mesothelioma Specialists
    Will make you aware of all your choices.
  3. Mesothelioma Surgeons
    Will help explore your treatment options and assist you in finding the best treatment ‘Team’ for you.

Dr. Robert Cameron

Dr. Robert Cameron is a a cardiothoracic surgeon and surgical oncologist who specializes in the treatment of malignant pleural mesothelioma. He is the Scientific Advisor of the Pacific Meso Center. He and his team of experts at the UCLA Medical Center have been treating mesothelioma patients for over 25 years.

Dr. Cameron is the innovator of the lung-sparing P/D surgical procedure for mesothelioma and has performed the procedure on over 300 patients to date. He has also published many articles, and is a frequent lecturer on the surgical and multi-modal management of pleural mesothelioma.

Dr. Cameron’s approach has always been

“Remove the tumor, save the lung and treat the disease as a chronic illness.”