Pleurectomy With Decortication

Pleurectomy with decortication (P/D) surgery is a popular treatment option for early-stage malignant pleural mesothelioma. It is known as the “lung-sparing” surgery because, unlike the extrapleural pneumonectomy (EPP), the lung is left intact while the lining and tumor masses are removed. P/D may relieve mesothelioma symptoms and possibly extend a patient’s lifespan.

Fact-Checked and Medically Reviewed By: Dr. Mark Levin

What Is Pleurectomy/Decortication?

Pleurectomy with decortication (P/D) is one of two surgical procedures used to treat malignant pleural mesothelioma (MPM). P/D is a lung-saving procedure that allows the patient to keep their lung. This minimizes future challenges involving strenuous activity. P/D helps increase patient life expectancy and improves quality of life.

The other surgical procedure for pleural mesothelioma is called the extrapleural pneumonectomy (EPP). This procedure involves removing the diseased lung.

P/D has proven to be a safe and highly successful method of treating pleural mesothelioma. It has been shown to increase patient life expectancy with a median survival time of 34 months after surgery.

P/D is used to treat early-stage (stage 1 and 2) pleural mesothelioma by removing as much of the tumor as possible from the pleural lining of the lungs and the surrounding chest cavity. Removing cancerous tissues in these areas reduces the spread of mesothelioma to nearby healthy tissues and organs.

Quick Facts About Pleurectomy with Decortication
  • Patients diagnosed at an early stage of pleural mesothelioma respond better to surgery.
  • Pleurectomy/decortication is a two-part surgery used to treat or manage pleural mesothelioma.
  • Approximately 2% of patients die during or immediately following pleurectomy and decortication surgery.
  • The probability of mesothelioma recurrence in the treated area following pleurectomy and decortication surgery is 65%.

The Pleurectomy/Decortication Procedure

Pleurectomy/decortication is split into two parts. The first part is the pleurectomy, and the second part is decortication.

Both decortication and pleurectomy are performed under general anesthesia. The entire operation takes roughly five hours and is led by a thoracic surgeon who specializes in pleural mesothelioma treatment.

It is important to remember that this mesothelioma surgery helps reduce disease symptoms and extends patients’ overall survival, but it will not cure mesothelioma.

If you or a loved one has been diagnosed with pleural mesothelioma and are investigating treatment options, our free checklist can help you prepare for your next doctor’s appointment.

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Mesothelioma Pleurectomy

The first part of pleurectomy and decortication surgery, the pleurectomy, involves the removal of the tissue lining the lungs, called the pleura. Only the lining of the lungs is removed. The lungs themselves are left intact.

In some cases, surgeons may not be able to determine the exact location or size of the tumor until the operation has begun.

Illustration showing a pleurectomy

During a pleurectomy procedure:

  1. The surgeon places the patient on their side and makes a long incision in the chest or thoracic cavity. This is called a thoracotomy.
  2. The surgeon removes the lining of the lung.
  3. The lung itself is left intact, but if there are visible tumors elsewhere, then the surgeon may remove parts of the chest wall lining, heart lining (pericardium), diaphragm, or lymph nodes.

When the tumor is larger or more integrated into surrounding tissues, a more extensive pleurectomy may be performed.

Once the diseased tissues have been carefully removed, the second part of the pleurectomy and decortication procedure, called decortication, begins.

Mesothelioma Decortication

The second part of pleurectomy/decortication surgical treatment involves the removal of visible tumors. Surgeons will use a variety of techniques to remove visible and unseen mesothelioma tumors and scrape the lung lining to reduce the chance of the cancer returning.

During a decortication procedure:

  1. The surgeon scrapes the lining of the lung with a scalpel to remove visible tumor growth in the cavity.
  2. Specialists then pack the area with hot gauzes and sponge packs to limit blood loss.
  3. Once the bleeding has slowed, the surgeon closes the incision with sutures.

The surgery takes around 5 hours and often causes a moderate amount of blood loss. For that reason, extra blood is always kept on-hand in case the patient needs an emergency transfusion.

Doctors will schedule follow-up appointments after the surgery to make sure the patient does not develop serious complications.

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Pleurectomy/Decortication Recovery

Recovery from a P/D surgical operation is critical and is one of the main reasons a patient must be in relatively good health before proceeding with the surgery.

Because the surgery is less radical than EPP, recovery from pleurectomy/decortication is usually shorter and less demanding. Patients should prepare for a month of recovery between the hospital and resting at home.

Family members, health care aids, and others may need to be involved to ensure a patient is comfortable and has an overall successful recovery.

Pleurectomy/Decortication Recovery Process

Most patients remain in the hospital for about a week, which is half the time of patients who undergo the more complex EPP procedure.

Following this thoracic surgery, patients must first breathe with the help of a ventilator, which delivers oxygen to the lungs via a tube through the mouth, nose, or neck.

Once the patient can breathe independently, chest tubes will be fitted to help inflate the lungs and drain pleural effusions (excess fluid), which can build up after surgery. This fluid can cause infection, so it is vital to remove it as quickly as possible.

Once the patient leaves the hospital, they may still need several weeks at home to fully recover.

Pleurectomy/Decortication Recovery Aid

Recovery aids such as complementary treatments and breathing or coughing exercises may be prescribed following pleurectomy and decortication. These recovery aids are intended to reduce the chance of infection and help a patient recover.

Recovery for P/D may involve:

  • Postoperative chemotherapy or radiation: Mesothelioma doctors may perform chemotherapy and/or radiation therapy to kill any remaining mesothelioma cells left behind during surgery.
  • Physical movement: Following surgery, patients are encouraged to start moving as soon as they are able. It is important for patients to walk and move to keep up their strength and make a speedy recovery.
  • Lung exercises: Patients will work with physiotherapists on breathing and coughing exercises. These exercises help to speed the recovery process and work to prevent infection by removing from the lungs of a mixture of saliva and mucus called sputum. Sputum often accumulates following lung surgeries.
  • Other aid: Additional treatments such as herbal remedies, a specific diet plan, physical therapy, or yoga may be recommended to relieve discomfort following surgery.

Once discharged from the hospital or cancer center, patients will be advised to continue walking and practicing their breathing and coughing exercises.

Although it is important for mesothelioma patients to remain active during the recovery process, they should also avoid overexerting themselves.

Pleurectomy/Decortication Risks and Side Effects

As with any surgical approach, there are risks and side effects that patients need to be aware of and P/D is no exception.

Overall, P/D is considered a lower risk surgery in comparison to EPP.

Mortality rates (number of deaths) during the procedure are higher for EPP at 2-7%, with P/D averaging 1-2%.

Recurrence of mesothelioma in other locations within the chest cavity is a risk in both procedures, although it is lower in EPP. That’s because all of the infected tissue is removed via total lung resection.

Potential risks and side effects resulting from P/D include:

  • Air leak (air leaking from the lungs)
  • Internal bleeding or blood clots
  • Lung or heart failure
  • Pneumonia and other infections
  • Reactions to general anesthesia

It is important for patients to discuss all the potential risks, side effects, and benefits with their mesothelioma specialist before making a treatment decision.

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Who Is a Good Candidate for Pleurectomy with Decortication?

P/D is offered to patients with early-stage pleural mesothelioma. A candidate for the surgery must also be in general good health to ensure that their body can cope with the stress of postoperative care.

Before undergoing P/D, patients may be assessed based on their:

  • Age: Younger patients may be better able to survive P/D and recover more quickly.
  • Mesothelioma cell type: Epithelioid mesothelioma patients respond better to surgery and other treatment than those with a different cell type (histology). Some doctors argue that sarcomatoid mesothelioma patients do not benefit from surgery.
  • Mesothelioma stage: P/D is far more likely to be effective if all visible cancer tumors are surgically removed. Late-stage mesothelioma may have progressed too far to be effectively removed through P/D.
  • Overall health: Patients who are in poor health may not be able to withstand serious surgery such as P/D.
  • Risk of cardiac or lung issues: Patients with health issues related to the lungs or heart may be at a higher risk of complications or death from P/D surgery.
  • Tumor location: Tumors growing too close to sensitive tissues may be too risky to remove.

Surgical oncologists use a preoperative screen to determine the best candidates for P/D and reduce unnecessary risks and complications.

The following tests are often carried out before surgery:

  • Blood tests to ensure blood can clot (to limit blood loss during surgery)
  • A pulmonary function evaluation to ensure the patient can breathe properly
  • CT or MRI scan of the chest to locate the tumor
  • A pleural biopsy to confirm malignant mesothelioma diagnosis
  • General fitness test
  • An echocardiogram to ensure the heart can perform properly during surgery

The ideal candidate is a patient in good overall health with a stage 1 mesothelioma diagnosis. Patients are most likely to be treated if the tumors have not spread past the lining of the pleura (lung).

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Pleurectomy/Decortication and Quality of Life

Pleurectomy/decortication may lead to both positive and negative changes in a patient’s quality of life. Mesothelioma patients should speak to their doctor to understand how pleurectomy/decortication could improve or impact their lives before deciding to undergo this surgery.

Many mesothelioma specialists and doctors recommend P/D over EPP to treat pleural mesothelioma. P/D is a less radical lung-sparing surgery, so it generally results in a better quality of life and a higher chance of surviving the surgery.

A literature review by R.M. Schwartz and other researchers published in 2018 looked at a pair of studies that compared the two surgeries and their impact on mesothelioma patients’ quality of life.

Patients who underwent EPP had significantly reduced lung function compared to P/D patients. Both procedures resulted in a significant decrease in the quality of life factors the studies measured following surgery. However, P/D patients returned to baseline levels after 12 months.

A study published in The Annals of Thoracic Surgery in January 2022 found that P/D and EPP both had similar cancer-related results but that patients who underwent P/D had much lower perioperative (around the time of surgery) mortality.

New Research on P/D and Chemotherapy

Researchers continue to study P/D to find ways to maximize its success. For example, several recent studies have looked at P/D in combination with chemotherapy.

A study published in the journal Thoracic Cancer in October 2022 found that patients had better short-term outcomes when they had extended P/D followed by chemotherapy over patients who had chemotherapy before extended P/D.

However, a recent clinical trial conducted by Japanese researchers found that chemotherapy followed by P/D boosted the median overall survival for patients by as much as 3.45 years. The results were published in June 2022 in the Journal of Thoracic and Cardiovascular Surgery.

Making a decision regarding your treatment plan can be overwhelming for you and your loved ones. However, our Patient Advocates are here for you 24/7. Reach out to us today for more information on P/D and other mesothelioma treatment options.

Pleurectomy With Decortication FAQs

What is pleurectomy surgery?

Pleurectomy surgery is an operation in which a surgeon removes the pleura, which is the tissue lining the lungs. However, the lungs are left intact. For this reason, it is referred to as the “lung-sparing” surgery.

If there are visible tumors elsewhere, the surgeon may remove parts of the chest wall lining, heart lining, and diaphragm.

Pleurectomy surgery is often performed as part of a two-part procedure known as pleurectomy with decortication, or P/D.

P/D is used to treat early stage pleural mesothelioma.

What is decortication of the lung?

Decortication of the lung is a surgery that removes fibrous tissue that has formed on the surface of the lung.

Decortication means to remove the outer layer from a structure.

Surgeons use different techniques depending on the patient’s medical condition.

Surgeons who perform mesothelioma decortication scrape the lung lining to remove visible tumors and cancerous cells.

Decortication of the lung is the second part of a procedure known as a pleurectomy with decortication, or P/D, that is often used to treat patients with malignant plural mesothelioma.

Reviewed by:Dr. Mark Levin

Certified Oncologist and Hematologist

  • Fact-Checked
  • Editor

Mark Levin, MD has over 30 years of experience in academic and community hematology and oncology. In addition to serving as Chief or Director at four different teaching institutions throughout his life, he is also still a practicing clinician, has taught and designed formal education programs, and has authored numerous publications in various fields related to hematology and oncology.

Dr. Mark Levin is an independently paid medical reviewer.

  • Board Certified Oncologist
  • 30+ Years Experience
  • Published Medical Author
Written by:

Lead Editor

Laura Wright is a journalist and content strategist with more than 15 years of professional experience. She attended college at the University of Florida, graduating magna cum laude with a bachelor’s degree in journalism in 2008. Her writing has been featured in The Gainesville Sun and other regional publications throughout Florida.

15 References
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  2. Breda C, Furia S, Lucchini G, Zaccaria A, Verderi E, Natale G, Lo Giudice F, Cavallin R, Ferronato A, Fontana P. Long-term outcomes after lung-sparing surgery for epithelial mesothelioma. J Thorac Dis. 2021 Nov;13(11):6283-6293. doi: 10.21037/jtd-21-691. PMID: 34992808; PMCID: PMC8662484.
  3. Cancer Research UK. “Surgery for Mesothelioma.” Retrieved December 2, 2022, from https://www.cancerresearchuk.org/about-cancer/mesothelioma/treatment/surgery

  4. Ricciardi, S., Cardillo, G., Zirafa, C. C., Carleo, F., Facciolo, F., Fontanini, G., Mutti, L., & Melfi, F. (2018). “Surgery for malignant pleural mesothelioma: an international guidelines review.” Journal of thoracic disease, 10(Suppl 2), S285–S292. Retrieved December 2, 2022, from https://doi.org/10.21037/jtd.2017.10.16

  5. Ploenes T, Osei-Agyemang T, Krohn A, Waller CF, Duncker-Rohr V, Elze M, et al. (2013). Changes in lung function after surgery for mesothelioma [online]. Date of Access: December 2, 2022. https://www.ncbi.nlm.nih.gov/pubmed/23430420

  6. Rena O, Casadio C. (2012). Extrapleural pneumonectomy for early stage malignant pleural mesothelioma: a harmful procedure [online]. Date of Access: December 2, 2022. https://www.ncbi.nlm.nih.gov/pubmed/22244608

  7. Urbach, DR. (2005). Measuring Quality of Life After Surgery [online]. Date of Access: December 2, 2022. https://www.ncbi.nlm.nih.gov/pubmed/16034507

  8. Schwartz, R.M., Lieberman-Cribbin, W., Wolf, A., Flores, R.M (2018). Systematic review of quality of life following pleurectomy decortication and extrapleural pneumonectomy for malignant pleural mesothelioma [online]. Date of Access: December 2, 2022. https://www.ncbi.nlm.nih.gov/pubmed/30497433

  9. Carbone, M., Bevan, H., Dodson, R., Pagano, I., Morris, P., Dogan, U, et al. (2012). Malignant Mesothelioma: Facts, Myths and Hypotheses [online]. Date of Access: December 2, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3143206/

  10. Vlahu, T., Vigneswaran, W.T. (2017). Pleurectomy and decortication. Annals of translational medicine, 5(11), 246. Date of Access: December 2, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5497109/

  11. Mangiameli G, Bottoni E, Voulaz E, Cariboni U, Testori A, Crepaldi A, Giudici VM, Morenghi E, Alloisio M. “Extended Pleurectomy/Decortication for Malignant Pleural Mesothelioma: Humanitas’s Experience.” Journal of Clinical Medicine. 2021; 10(21):4968. Retrieved from: https://doi.org/10.3390/jcm10214968. Accessed on December 1, 2022.

  12. Falanga F, Rinaldi P, Primiceri C, Bortolotto C, Oneta O, Agustoni F, Morbini P, Saracino L, Eleftheriou D, Sottotetti F, Stella GM. “Feasibility and safety of extended pleurectomy/decortication for malignant pleural mesothelioma. A single group experience.” Thoracic Cancer. 2022 Oct;13(19):2792-2798. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/36052736/. Accessed on December 1, 2022.

  13. RWJBarnabas Health. “Decortication.” Retrieved from: https://www.rwjbh.org/treatment-care/surgery/thoracic-surgery/thoracic-surgery-tests-and-procedures/decortication/. Accessed on December 1, 2022.

  14. Zhou N, Rice D, Tsao A, Lee P, Haymaker C, Corsini M, Antonoff M, Hofstetter W, Rajaram R, Roth J, Swisher S, Vaporciyan A, Walsh G, Mehran R, Sepesi B.
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    Retrieved from: https://www.sciencedirect.com/science/article/abs/pii/S0003497521008468. Accessed on December 2, 2022.

  15. Hasegawa S, Yokoi K, Okada M, Tanaka F, Shimokawa M, Daimon T, Nakano T. “Neoadjuvant pemetrexed plus cisplatin followed by pleurectomy for malignant pleural mesothelioma.” Journal of Thoracic Cardiovascular Surgery. 2022 June. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/34419248/. Accessed on December 2, 2022.

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