Pleurectomy with Decortication (P/D)

Quick Summary

Pleurectomy with decortication surgery is a treatment option for patients with early-stage pleural mesothelioma. It is a two-part procedure that involves: 1) removing the lung lining and other diseased tissue in the chest cavity; and 2) removing tumors. The lung itself is spared.

Pleurectomy with Decortication Overview

Patients with stage 1 and stage 2 mesothelioma who are in good overall health may be good candidates for pleurectomy with decortication (P/D). In most cases, the mesothelioma must not have metastasized (spread) beyond the lung area. Some patients with advanced-stage mesothelioma may be eligible for palliative P/D surgery.

During the pleurectomy, the surgeon removes the lining of the lung (pleura), as well as affected parts of the heart lining (pericardium), diaphragm, and other chest cavity tissue as necessary. During decortication, the surgeon resects (removes) tumors in the lung area.

The procedure is often life-extending, and patients who undergo P/D may live months or even years longer than those who did not receive surgery. Patients who combine surgery with other treatments can extend their life expectancy further.

Risk of complications is relatively low for P/D surgery, and the short-term mortality rate is less than 5%. However, the probability of mesothelioma recurring in the affected area after P/D is considered high at 65% compared to the other type of alternative surgery—extrapleural pneumonectomy—which has a recurrence rate of 33%.

Who Is Eligible for Pleurectomy with Decortication?

The goal of P/D surgery is to remove cancer cells before they have metastasized beyond the chest cavity. Therefore, only patients with early stages of mesothelioma are considered eligible for curative P/D.

Patients must be in good overall health to handle the surgery.

Some considerations include:

  • Age—younger patients are usually healthier than older patients
  • Gender—women have better overall survival and recovery rates
  • Other health conditions
  • Whether you are a smoker
  • General fitness level

In some cases, patients with advanced stages of mesothelioma may be eligible for P/D—so long as they are fit to handle the surgery. The goal for these patients is to reduce pleural mesothelioma symptoms, such as difficulty breathing, by removing tumor masses.

Benefits of Pleurectomy with Decortication

Pleurectomy with decortication was originally developed as a palliative procedure to relieve painful mesothelioma symptoms. However, recent medical advancements have made P/D effective as a curative treatment.

The average life expectancy following P/D surgery is 8 to 22 months. In the right candidates, the 5-year survival rate after P/D improves to 30–40%.

Symptom-relieving benefits still exist with P/D surgery. After approximately one month of recovery, patients are often able to regain enough breathing function to resume activities that were previously too difficult.

P/D is often called the “lung-saving” surgery as the diseased lung is spared—unlike extrapleural pneumonectomy, which removes the affected lung. Debate exists among medical professionals about the effectiveness of both procedures. It is crucial that patients consult with a mesothelioma specialist to determine their optimal treatment plan.

Pleurectomy with Decortication Procedure

P/D is an extensive, two-part open surgery. The operation is complex, and patients should understand the medical processes to expect before, during, and after the procedure.

Before Surgery

Doctors run several pre-operative tests to ensure P/D surgery remains in your best interest. Lung and cardiac fitness are tested to make sure your body can withstand the rigors of surgery and recovery. A blood test ensures blood can clot during the operation. A chest scan is ordered to locate the tumor and confirm that cancer has not spread beyond the thoracic cavity.

During Surgery

P/D surgery is performed under general anesthesia. The pleurectomy begins with the surgeon making an incision along your back and side to access the chest cavity. The surgeon may make additional incisions if multiple access points are required. Once inside the chest cavity, the surgeon removes the pleura and, if necessary, parts of the pericardium, diaphragm, and other diseased tissue.

Decortication begins after the affected tissue is removed. At this stage, the surgeon carefully resects (removes) visible tumors and scrapes the lung lining to eliminate any unseen mesothelioma. The medical team layers the lung space with gauze to minimize blood loss during this phase. The surgeon may also use photodynamic therapy to kill cancer cells with light energy.

The surgeon closes the incision with stitches when confident that all visible mesothelioma is removed. The entire procedure lasts about five hours.

Recovery

Recovery from P/D surgery is extensive. Patients should expect a one-week recovery in the hospital. During this time, doctors closely monitor your vitals for postoperative complications affecting your heart and lungs, for infection, and for any blood loss continued from decortication.

At first, a ventilator assists you with breathing, and an IV administers medications and fluids. Respiratory exercises begin soon after you can breathe without assistance. These exercises will help you regain breathing function and also drain any built-up lung fluid (preventing pneumonia).

At-home recovery time is approximately one month. Breathing exercises along with dietary and exercise regimens continue during this time. In most cases, patients regain their ability to carry out tasks and hobbies that were too difficult before surgery.

P/D as Part of Multimodal Therapy

Pleurectomy with decortication is most effective in extending your life when combined with other treatments in a multimodal approach.

Depending on your specific case, doctors may recommend one or more of the following therapies to accompany P/D surgery:

  • Chemotherapy: Powerful drugs administered intravenously (IV). Chemotherapy may be recommended before surgery to shrink tumors, or after surgery to kill any remaining cancer cells.
  • Radiation: Used to shrink tumors, and to kill cancer cells remaining after surgery. Radiation can be used with accuracy, allowing for high-dose treatments that do not damage the lungs and other unaffected organs.
  • Alternative treatments: Generally used to relieve discomfort and symptoms. Alternative treatments are not curative but aid your overall ability to fight cancer. Options may include special nutrition and herbal medicines, physical therapy, yoga, massage and more.

Risks & Side Effects of P/D

Pleurectomy with decortication is a complex open surgery. Medical advancements in recent years have made P/D safer, but a risk of complications remains. The 30-day mortality rate of P/D is less than 5%.

Potential risks and side effects of P/D include:

  • Internal bleeding
  • Infection
  • Pneumonia
  • Blood clotting
  • Prolonged air leaks (pneumothorax)

Operating on and near vital organs carries an increased probability of serious complications during and after the surgery, including cardiac and respiratory failure. Doctors will monitor you closely for signs of these risks.

Patients may also experience side effects associated with general anesthesia, such as nausea, dizziness, discomfort, and temporary confusion. In rare cases, general anesthesia causes serious reactions, including rapid fever, delirium, and cognitive dysfunction.

While P/D is beneficial for sparing the affected lung, the likelihood of removing all affected tissue is lower than extrapleural pneumonectomy surgery that removes the entire lung. Therefore, the probability of local recurrence (when the mesothelioma comes back after being removed) is high at 65%

If you have been diagnosed with mesothelioma, it is crucial to get a second opinion and create a detailed treatment plan that is best suited to your unique case. Contact a Mesothelioma Help Now Patient Advocate today to begin discussing your treatment.

View Author and Sources
Author

Sources
  1. Annals of Cardiothoracic Surgery, “Pleurectomy/decortication, chemotherapy, and intensity modulated radiation therapy for malignant pleural mesothelioma.” Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3741800/#__sec5title. Accessed on February 12, 2018.
  2. Annals of Translational Medicine, “Pleurectomy and decortication.” Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5497109/. Accessed on February 12, 2018.
  3. Expert Review of Respiratory Medicine, “Surgery for Malignant Pleural Mesothelioma.” Retrieved from: https://www.medscape.com/viewarticle/724140. Accessed on February 12, 2018.

Last modified: May 7, 2018