Surgical Choices: Pleurectomy with Decortication

A pleurectomy / decortication (P/D) is an operation for mesothelioma that removes the involved pleura and frees the underlying lung so that it can expand and fill the pleural cavity.

The pleural space is a potential cavity between the lung and the chest wall-more specifically, between the visceral pleura and the parietal pleura. In the average healthy patient, this space is less than 1 mm thick. There are a number of pathologic processes that can alter the transport of cells and fluid within this space and thus give rise to clinically significant sequelae.

One such process is fibrothorax, which is defined as the presence of abnormal fibrous tissue within the pleural space, resulting in entrapment of the underlying pulmonary parenchyma (a state variously referred to as trapped lung, restrictive pleurisy, or encased lung).

Decortication is the surgical procedure by which this restrictive fibrous layer is peeled away from the lung; the literal meaning of the term is the stripping away of a rind. The technical goals of the operation are to re-expand the lung and resolve the pathologic process affecting the pleural space so that pulmonary function and chest wall mechanics will improve and the patient's symptoms will be relieved.

(courtesy of www.medscape.com)

Steps in P/D Operative Technique for Malignant Pleural Mesothelioma

  1. Incision and exposure of parietal pleura

  2. Dissection of parietal pleura from endothoracic fascia, diaphragm, and mediastinum*

  3. Incision of the parietal pleura and exposure of the visceral pleura

  4. Decortication of the visceral pleura

  5. Reconstruction

* May need en bloc resection of diaphragm or pericardium


Additional Information

Radical Pleurectomy and Intraoperative Photodynamic Therapy for Mesothelioma (5/2012)

Study's results showed it was possible to achieve a macroscopic complete resection using lung-sparing surgery in 97% of patient group with stage III/IV disease. It concludes that the results of this lung-sparing approach are safe and encouraging. More... 


Prospective Study on Functional Results After Lung-Sparing Radical Pleurectomy (5/2012)

Lung-sparing Radical pleurectomy leads to significant improvement of pulmonary function and perfusion after a recovery time of 2 months. Functional results are better after preservation of the diaphragm. Preservation of physiological reserve via lung-sparing Radical pleurectomy might allow patients with MPM to be eligible for further therapeutic options in the long term. More...


Pleurectomy/Decortication is Superior to Extrapleural Pneumonectomy in the Multimodality Management of Patients with Malignant Pleural Mesothelioma (4/2012)

Dr. Lang-Lazdunski's study finds that P/D, hyperthermic pleural lavage with povidone-iodine and adjuvant chemotherapy were superior to neoadjuvant chemotherapy, EPP and adjuvant radiotherapy. More...


Is it Time to Consider Pleurectomy and Decortication as the Only Surgical Treatment for Malignant Pleural Mesothelioma? (4/2012)

Peer-review of Dr. Lang-Lazdunski's study on P/D concludes that it provides additional data that should lead us to consider P/D in all trials of treatment for mesothelioma. However, it is too early based on this data to completely abandon EPP altogether. More... 


Recent Bio-Medical Breakthroughs On A Pleurectomy With Decortication and Mesothelioma (2/14/2012)

Sam (age 14) lost his grandmother Trudie to Mesothelioma in 2007. He chose to write about his experience for his science class in a paper titled: “Recent Bio-Medical Breakthroughs on a Pleurectomy with Decortication and Mesothelioma”. He hopes that, with continued research, a cure will be found so more people won’t have to lose family members to this horrible disease. More...


Quantitative Measurement of Lung Re-expansion in Malignant Pleural Mesothelioma Patients Undergoing Pleurectomy/Decortication (3/2011)

This study provided objective evidence that pleurectomy/decortication (P/D) allows a trapped lung to re-expand, quantifies the re-expansion based on scans, and investigates whether the expansion persists after surgery. It found that debulking of mesothelioma with P/D substantially increased the ipsilateral lung volume relative to both the presurgical ipsilateral volume and the contralateral lung volume. This improvement persisted months after surgery. More...


Pleurectomy/Decortication Effective as the Surgical Arm of Multimodal Therapy for Malignant Pleural Mesothelioma: Presented at EMCTO (5/12/09)

Researchers at the University of Pisa in Italy have concluded in the February, 2007 issue of the Journal of Thoracic Oncology that pleurectomy-decortication surgery combined with chemotherapy produces a favorable survival rate for patient with malignant pleural mesothelioma. More...


Longer Survival with Pleurectomy/Decortication and Interleukin 2 (10/20/08)

Discussion of “A phase II study of intrapleural immune-chemotherapy, pleurectomy/decortication, radiotherapy, systemic chemotherapy and long-term sub-cutaneous IL-2 in stage II-III malignant pleural mesothelioma” by Marco Lucchi et al., European Journal of Cardio-thoracic Surgery, 2007
Patients considering surgical treatment for their malignant pleural mesothelioma have a difficult time choosing between the extrapleural pneumonectomy (EPP) and the pleurectomy/decortication (PD) More...


Radical Pleurectomy/Decortication Saves Patients Bypassed by EPP (10/13/08)

Review and discussion of “Open lung-sparing surgery for malignant pleural mesothelioma: the benefits of a radical approach within multimodal therapy” by Apostolos Nakas et. al., European Journal of Cardio-thoracic Surgery, 2008

When doctors first began treating malignant pleural mesothelioma with surgery, the extrapleural pneumonectomy (EPP) was considered the best option for extending life. Doctors are no longer sure that is the case. One of the most recent articles reviewing 633 surgeries concluded that when other factors are taken into account, EPP’s superiority over pleurectomy/decortication (PD) is unclear. More...


Surgery and Mesothelioma: Why Operate? (10/08/08)

Review and discussion of “Macroscopic complete resection: The goal of primary surgery in multimodality therapy for pleural mesothelioma,” by David J. Sugarbaker, Journal of Thoracic Oncology, 2006

Few medical treatments make as much intuitive sense as surgery. When something inside is broken or diseased or useless, the right surgery can often repair it or remove it. Cancers can be especially susceptible to surgical cures, particularly when combined with chemotherapy and radiation. More...


Video-assisted Pleurectomy/Decortication to Treat Mesothelioma in Elderly Patients (10/08/08)

A few years ago, mesothelioma patients who elected to treat their cancer with surgery were almost invariably steered towards the extrapleural pneumonectomy, or EPP. No randomized trials comparing surgery with an alternative treatment or comparing EPP to other procedures such as pleurectomy/decortication (PD) have ever been done More...


Society of Thoracic Surgeons 42nd Annual Meeting. January 30 - February 1, 2006. Chicago, Illinois (11/07/07)

Improved survival with Interferon Alpha maintenance therapy following pleurectomy / decortication and radiation for malignant pleural mesothelioma. As presented by Dr. Robert Cameron. More...


Standing Strong Against Mesothelioma: California Water Works Contractor and Dr. Cameron Team Up to Remove Deadly mesothelioma Tumor. Colfax, CA (10/08/07)

In one hour, 68 year-old Kermit Kelley was about to undergo life-altering surgery. It was nine a.m. in the pre-op staging area at UCLA's David Geffen School of Medicine. A steady stream of nurses and doctors had been visiting Kermit since seven o'clock, hooking him up to this, inserting that. More...


Pleurectomy / Decortication Surgery Preferable to Extra-Pleural Pneumonectomy (Sept., Oct. 2007)

The September/October issue of Thoracic Surgery News reports that the two surgical options typically used for pleural mesothelioma produce similar outcomes. However, the pleurectomy / decortication surgery spares the entire lung, and removes the the pericardium and diaphragm only when necessary. More...


Four-modality Therapy in Malignant Pleural Msothelioma: a Phase II Study (3/07)

Treatment approaches in malignant pleural mesothelioma (MPM) patients range from mere palliation to aggressive anticancer therapy, and there is currently no consensus on the optimal therapeutic strategy. In 1999, we began a phase II study to investigate four-modality treatment of advanced stage MPM. More...


Phase II Italian Researchers: P/D Shows Favorable Survival Rate (3/07)

Researchers at the University of Pisa in Italy have concluded in the February, 2007 issue of the Journal of Thoracic Oncology that pleurectomy-decortication surgery combined with chemotherapy produces a favorable survival rate for patient with malignant pleural mesothelioma. More...


Is Extrapleural Pneumonectomy the Preferred Surgical Management in the Multi Modal Treatment of Mesothelioma? Dr. Cameron weighs in against the EPP (Annals of Surgical Oncology, 2006) More...

  • No evidence the EPP is superior to lung-sparing P/D
  • Both surgeries carry potentially serious risks
  • Only experienced surgeons should attempt either surgery
  • "The EPP should not become the (Sir Edmund Hillary) operation of Thoracic Surgery: being done simply because it is there and because it can be done ks

Anatomy of a Successful P/D (photos)
Dr. Robert Cameron, September 13, 2005 (9/14/05) More...


"Rational Versus Radical Therapy For Mesothelioma: A New Approach," Dr. Robert Cameron, UCLA Medical School, presented at MARF Symposium in Las Vegas, October 16, 2004. (11/18/04) More...


"Radical pleurectomy / decortication and Intraoperative Radiotherapy Followed by Conformal Radiation with or without Chemotherapy for Malignant Pleural Mesothelioma" Terry T. Lee, MD, et al, J Thorac Cardiovasc Surg 2002; 124:1183-9 (Posted 5/21/04)

A retrospect review of the efficacy and morbidity of radical pleurectomy / decortication and intraoperative radiotherapy followed by external beam radiation therapy with or without chemotherapy for diffuse malignant pleural mesothelioma. (The Journal of Thoracic and Cardiovascular Surgery - Volume 124, number 6 2002) More...

  • 32 patients with MPM studied from 1995 to 2000. Median survival from date of operation was 18.1. Median time from operation to progression of tumor was 12.2 months.
  • Local control main problem in treating MPM patients, as surgery does not eradicate all tumor. Need for adjuvant therapy (i.e., post surgery chemo, intraoperative heated chemo perfusion, etc.)
  • Median age in cohort was 69 years compared to 57 years in Sugarbaker series; median survival rates comparable (18.1 months vs. 19 months).

"A Phase II Trial of pleurectomy / decortication Followed by Intrapleural and Systemic Chemotherapy for Malignant Pleural Mesothelioma" V. Rusch, et al, Journal of Clinical Oncology, Vol 12, 1156-1163, 1994 (Posted 5/21/04)

Conclusion. This short but aggressive combined modality regimen was generally well tolerated, but should not be used outside of a protocol setting because of the potential for serious toxicity. Overall survival was as good or better than with previously reported multimodality approaches, but other strategies are needed to improve local control. More...


John R. Roberts, MD, FCCP, "Surgical Treatment of Mesothelioma: Pleurectomy" Division of General Thoracic Surgery, Department of Cardiac and Thoracic Surgery, Vanderbilt Hospital, Nashville, TN 1999 (Posted 5/21/04)

  • No studies have randomized similarly staged patients to pleurectomy or extrapleural pneumonectomy (EPP); thus the most effective surgery for patients with MPM has not been defined.
  • Although no difference in overall survival between the two procedures, there was significant improvement in disease-free survival for those undergoing EPP compared with pleurectomy.
  • Pleurectomy can be safely performed. The addition of postoperative phototherapy or intrapleural chemotherapy does not improve long-term survival or result in symptom palliation.
  • Limited data suggest that EPP may give greater chance of long-term survival in patients with favorable histology and earlier stage disease

M.W. Grossebner, et al, "Mesothelioma - VATS biopsy and lung mobilization improves diagnosis and palliation" Eur J Cardiothorac Surg 1999;16:619-623 (Posted 5/21/04)

Conclusions: VATs provides adequate tissue for histological diagnosis where other methods fail. At the same operative sitting it provides a therapeutic intervention that allows drainage of effusion cytoreductive pleurectomy and lung mobilization in a significant number of cases. Where the pleural space can be closed this results in significantly fewer hospital admissions and appears to improve quality of life and length of survival. The price is a longer hospital stay due to prolonged air leak. More...