Pleurectomy/decortication (P/D) is the most commonly performed surgical procedure for pleural mesothelioma. It is a two-part, lung-sparing operation that removes the pleural lining and all visible tumors while preserving the lung itself. For patients who qualify, P/D offers a meaningful extension of survival with a lower rate of serious complications than the alternative lung-removing surgery. Understanding what P/D involves, who is eligible, and how it compares to other options is essential for making informed decisions about treatment.
At The Williams Law Firm, P.C., Attorney Joseph P. Williams has represented hundreds of mesothelioma patients and their families and has never lost a mesothelioma case. If you or a loved one has been diagnosed with pleural mesothelioma, legal options may be available to help cover medical costs, lost income, and other losses.
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A pleurectomy/decortication is a two-stage surgical procedure. In the first stage (pleurectomy), the surgeon removes the pleura, the thin two-layer membrane that surrounds the lungs and lines the chest wall. In the second stage (decortication), the surgeon removes any visible tumor masses remaining on the surface of the lung, the chest wall, the diaphragm, and the pericardium. Because the lung itself is left in place, P/D is considered a lung-sparing surgery.
There are two main variants of the procedure. A standard P/D removes both the parietal pleura (which lines the chest wall) and the visceral pleura (which covers the lung surface). An extended or radical P/D (eP/D) goes further, also removing the diaphragm and/or the pericardial sac if cancer has spread to those structures, which are then reconstructed with synthetic materials. The extended version is used when cancer is more locally advanced but has not spread beyond the chest cavity.
The entire surgery typically takes four to six hours and is performed under general anesthesia with the patient positioned on their side. It must be performed at a major cancer center by a thoracic surgeon experienced in mesothelioma operations.
The two standard surgical options for pleural mesothelioma are P/D and extrapleural pneumonectomy (EPP). Understanding the difference is important because they represent different philosophies of surgical management and have different risk profiles.
EPP is the more radical procedure. It removes the entire affected lung, the pleura, the diaphragm on the affected side, and portions of the pericardium. Because the lung is removed, EPP is a more complete cytoreduction but also carries a substantially higher rate of serious complications. Mortality rates for EPP range from 2 to 6 percent at experienced centers, with major complication rates around one in three patients. Recovery is more prolonged and the impact on quality of life more significant.
P/D preserves the lung and has a lower perioperative mortality rate. Studies comparing the two procedures have not shown EPP to produce consistently better survival outcomes than P/D, which has led most mesothelioma centers to favor P/D as the preferred surgical approach for eligible patients. According to the American Cancer Society, EPP is now less commonly performed than P/D for this reason. The choice between them depends on the extent of disease, tumor cell type, and the patient’s overall health and lung function.
| Feature | P/D | EPP |
|---|---|---|
| Lung preserved? | Yes | No — lung removed |
| Surgery duration | 4 to 6 hours | 5 to 8 hours |
| Hospital stay | 5 to 10 days | 10 to 14 days |
| Mortality rate (major centers) | Under 2% | 2 to 6% |
| Median survival (with multimodal therapy) | 2 to 3 years | Comparable to P/D |
| Current preference | Preferred at most centers | Less commonly performed |
Not every patient with pleural mesothelioma is a candidate for P/D. Eligibility is determined by a combination of disease-related and patient-related factors that the surgical team evaluates through a series of pre-operative tests.
From a disease standpoint, P/D is most appropriate for patients whose cancer has not spread extensively beyond the pleural cavity. It is best suited for stage 1 and stage 2 pleural mesothelioma and is more likely to be offered for the epithelioid cell type, which responds better to surgery than sarcomatoid or biphasic subtypes. If tumor burden has spread extensively into the lung parenchyma, the diaphragm, or distant lymph nodes, the surgeon may determine that sufficient cytoreduction is not achievable with P/D.
From a patient health standpoint, candidates must have adequate lung function to tolerate the operation and recovery. Pulmonary function tests and a cardiac stress test are standard pre-operative requirements. Non-smokers or former smokers who have been abstinent for an extended period have better surgical outcomes. Patients with significant other medical conditions, such as heart failure or severe COPD, may not be appropriate candidates regardless of disease stage.
Pre-operative preparation typically begins several weeks before surgery. You may need to stop taking blood thinners or nonsteroidal anti-inflammatory drugs in advance. If you smoke, cessation well before surgery significantly reduces anesthetic and respiratory risks. Your team will perform pulmonary function tests, an echocardiogram, blood work, and imaging to confirm your suitability for the procedure. A multidisciplinary tumor board at a mesothelioma center will typically review your case before finalizing the surgical plan.
You will receive general anesthesia and a breathing tube will be placed. You are positioned on your side to allow access to the chest. The surgeon makes an incision between the ribs and performs the pleurectomy, carefully dissecting and removing the parietal and visceral pleura while preserving the underlying lung tissue. The decortication phase then removes all visible tumor nodules from the lung surface, chest wall, diaphragm, and pericardium. If an extended P/D is performed, the diaphragm or pericardium is then reconstructed with synthetic mesh or patch material. A chest drain tube is placed before closing to drain any postoperative fluid accumulation.
Most patients spend five to ten days in hospital following P/D. You will be monitored for complications including bleeding, infection, irregular heart rhythm, pneumonia, and fluid accumulation. Nurses will encourage you to begin moving and walking within a day or two of surgery to reduce the risk of blood clots and speed recovery. The chest tube is typically removed within a few days once drainage subsides. Full recovery to normal activity generally takes six to eight weeks, during which pulmonary rehabilitation is often recommended to restore lung function and exercise tolerance. Most patients report meaningful improvement in breathlessness and chest discomfort following the procedure.
Studies show the average survival after P/D surgery is two to three years, compared to a median of six to twelve months without surgical intervention. Some patients live five or more years after P/D, particularly those with early-stage epithelioid disease who receive multimodal treatment combining surgery with chemotherapy and/or immunotherapy. A 2018 study published in the Journal of Thoracic and Cardiovascular Surgery reported a median overall survival of 22 months in 49 patients who underwent P/D combined with localized chemotherapy, with zero deaths within 90 days of surgery.
P/D is most often combined with adjuvant chemotherapy using pemetrexed and cisplatin, the standard first-line regimen for pleural mesothelioma. Some centers also deliver hyperthermic intrathoracic chemotherapy (HITHOC) directly into the chest cavity at the time of surgery to target residual microscopic disease. Radiation therapy and immunotherapy may also be incorporated into the treatment plan depending on the center and the individual patient’s case.
As with any major thoracic surgery, P/D carries significant risks. These include bleeding during or after the procedure, infection at the surgical site, respiratory complications including pneumonia or partial lung collapse (pneumothorax), arrhythmias (irregular heart rhythm), fluid accumulation in the chest (recurrent pleural effusion), and in rare cases injury to surrounding structures. Because the ribs must be spread during surgery, postoperative pain at the incision site is expected and managed with medication. Serious complications are less common with P/D than with EPP, and the operative mortality rate at experienced centers is under 2 percent.
The primary benefit of P/D is that it preserves the lung while still achieving meaningful cytoreduction. By leaving the lung in place, patients typically experience better respiratory function after recovery than EPP patients, who must compensate with a single remaining lung. Most patients report significant relief from the shortness of breath and chest pain caused by pleural effusion and pleural thickening, often within weeks of surgery. Studies have not shown EPP to produce superior survival outcomes compared to P/D, which means the lung-sparing approach offers comparable survival benefit with better quality of life. For patients who respond to immunotherapy or chemotherapy prior to surgery, P/D may remain an option even when the tumor has initially appeared borderline resectable.
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If you have been diagnosed with pleural mesothelioma and are being evaluated for or recovering from P/D surgery, you may be entitled to significant financial compensation to help cover surgical costs, hospitalization, lost income, and pain and suffering. In New York, the statute of limitations for a personal injury claim is three years from the date of your mesothelioma diagnosis. In New Jersey it is two years. Contact The Williams Law Firm, P.C. through our contact form to schedule a free consultation. You pay nothing unless we win.
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The goal of P/D is to remove the diseased pleural lining and all visible tumor from the chest cavity, allowing the lung to expand more easily and reducing symptoms such as breathlessness and chest pain. Because it preserves the lung, P/D aims to improve both survival and quality of life. It is most effective as part of a multimodal treatment plan that also includes chemotherapy and possibly immunotherapy.
The procedure typically takes four to six hours, depending on the extent of disease and whether an extended P/D is required. The patient is under general anesthesia throughout. More complex cases involving diaphragm or pericardial involvement may take longer.
Most patients spend five to ten days in hospital after P/D. Full recovery to normal activity typically takes six to eight weeks. Pulmonary rehabilitation is often recommended during recovery to restore breathing strength and exercise tolerance. Patients typically notice significant improvement in breathlessness and chest discomfort within a few weeks of discharge.
P/D preserves the lung while EPP removes it entirely. Both aim to remove as much disease as possible, but studies have not consistently shown EPP to produce better survival outcomes than P/D. Because P/D carries a lower rate of serious complications and better preserves quality of life, most mesothelioma centers now favor P/D for eligible patients. EPP may still be considered for patients where more extensive resection is judged necessary by the surgical team.
Yes, in almost all cases. Surgery alone is rarely sufficient because microscopic tumor cells cannot all be removed visually. Standard of care following P/D typically includes chemotherapy with pemetrexed and cisplatin. Some centers also deliver hyperthermic intrathoracic chemotherapy (HITHOC) directly into the chest cavity at the time of surgery. Immunotherapy and radiation may also be incorporated depending on your specific case and cell type.
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