Pleurectomy/decortication (P/D) is a lung-saving surgical option for pleural mesothelioma patients. During a P/D, the lining of the affected lung (pleura) is removed, while the lung remains intact. The surgeon also attempts to extract the tumor in its entirety if it has not spread past the pleura.
A pleural mesothelioma patient who receives a pleurectomy/decortication (P/D) procedure will often have a longer life expectancy than other patients, ranging from 9 to 19 months after surgery. A P/D typically has few complications and low mortality rates. However, not everyone is eligible for the surgery.
Patients who are healthy overall, who are fit enough to handle the stress of surgery, and who are diagnosed with earlier stages of pleural mesothelioma are considered good candidates for a P/D. Once the tumor has metastasized and the cancer has reached a later stage, the likelihood that this procedure can remove a majority of the tumor growth is slim.
There may be other surgical options available for patients who do not qualify for a P/D, including an extrapleural pneumonectomy.
A pleurectomy/decortication is one procedure, performed in two parts. The first part is a pleurectomy, and the second part is a decortication. The P/D procedure lasts approximately five hours. The patient is placed under general anesthesia before the surgery begins.
A pleurectomy is where an experienced mesothelioma surgeon opens the chest cavity, or the thoracic cavity, and removes the lining of the lung. A pleurectomy is a type of palliative treatment, which means it is meant to relieve symptoms caused by fluid in the thoracic cavity and extend a person’s life rather than try to cure the disease. It creates space for the lung to expand and can relieve chest pain, remove fluid buildup in the chest and improve breathing.
With a decortication, the goal is to remove all tumor growth inside the pleural lining.
To perform a pleurectomy, the surgeon makes a laceration along the back of the torso. The laceration begins around the sixth rib, and extends downward, parallel to the spine. The cut then extends outward parallel to the ribs. The incision allows surgeons the best access to the thoracic cavity. The surgeon may make another small incision if the tumor is large and extends into the lower half of the thoracic cavity.
Once the surgeon has maximum exposure to the tumor, the outside lining of the lungs, or the parietal pleura, is removed, as well as the affected chest wall, diaphragm or pericardium.
If the tumor is pervasive and cannot be removed entirely, a patient may undergo a pleurectomy without the decortication.
The same surgeon then performs the decortication. The surgeon might scrape the lining of the lung to more effectively remove as much of the cancer as possible, but the lung is left intact.
At this time, the surgeon will also pack the open chest cavity with gauze or similar material to minimize blood loss. Then, once the bleeding is minimal and all visible tumor growth has been removed, the surgeon closes the incision with stitches.
After surgery, a patient can experience some blood loss and should expect about a week-long hospital stay for monitoring. Once the anesthesia wears off and the patient is awake, they are moved to a recovery room where their vitals such as heart rate, respiration rate, blood pressure and temperature are closely monitored.
Patients breathe with the assistance of a ventilator, a machine that delivers oxygen to the lungs through a tube, directly after surgery. The tube can be placed in the patients’ mouth, nose or a small hole in the neck. The medical care team will wean the patient off the ventilator as soon as the patient’s vitals are stable and they believe the patient is able to breathe without assistance.
Other factors that affect when a patient can be taken off ventilation and breathe on their own include pain level, muscle fatigue, proper kidney function and the removal of any continuous IV sedation.
In most cases, a spontaneous breathing trial is run, which allows the patient to attempt to breathe on their own while they are still connected to a ventilator. This test will predict if the patient is ready to breathe on his or her own. At this time, the patient may be instructed to practice deep breathing to avoid infection and work out the diaphragm after being on a ventilator.
During recovery, patients will also be fitted with chest tubes to help inflate the lungs during breathing and to help drain any excess fluid built up after surgery, which can cause infection. Coughing exercises can also help remove fluid buildup and strengthen the diaphragm.
A second pulmonary function test may be run to ensure the surgery didn’t affect the patient’s breathing and lung capability. Occasional complete blood count tests may also be run to make sure there is no infection.
Once the patient is released from the hospital, at-home recovery may last a few weeks. Patients who experience pain or other symptoms after surgery may qualify for complementary rehabilitation treatment.
Reasons to undergo a P/D vary from case-to-case. While P/D is commonly used as a form of potentially curative treatment, it can also relieve pain and increase quality of life. In one study of 100 patients, P/D successfully alleviated major symptoms including chest pain, cough and shortness of breath, and successfully treated pleural masses and controlled the build up of fluid (pleural effusions).
Not every patient is eligible to receive a P/D. An ideal candidate for this type of surgery has an early stage of cancer, is in otherwise good health and has a tumor that has not spread (metastasized) past the lining of the lung (the pleura).
Any type of surgery puts stress on the body, especially the heart, and suppresses the immune system as the skin and underlying tissues are disrupted. A healthy immune system is vital to help a patient heal properly after surgery. To ensure that a patient can withstand the stress put on the body during and after surgery, the patient must be physically fit and in otherwise good health.
Candidates may be subject to a pre-operative evaluation, which may include:
Patients in the later stages of pleural mesothelioma may not qualify for P/D, because later stages indicate that the cancer has spread and the removal of just the lining of the lung would be impractical, or the tumor has reached areas that are too difficult for a surgeon to remove without damaging the lung or other organs.
Pleurectomy/decortication is associated with a high success rate. Approximately 90 percent of patients who have the surgery experience a significant reduction in symptoms. Studies show that P/D can also increase a patient’s life expectancy, with median survival rates of 20 months, almost one year longer than other mesothelioma patients.
Patients who receive other treatment before or after surgery generally have even better life expectancies. Studies suggest the best approach for increasing survival is utilizing a multimodal treatment approach, which combines more than one type of treatment, usually chemotherapy, surgery and radiation. A 2009 study indicated that patients who used a multimodal approach experienced an average survival of 30 months.
P/D also has a low mortality rate. For every 100 patients who receive this surgery, one to four people may die.
Although success rates are high and mortality rates are low, just like with any type of surgery, complications may arise during surgery. About one in 10 patients experience a prolonged air leak. Other complications that may arise during surgery include internal bleeding, blood clots, respiratory or cardiac failure, pneumonia and/or infection.
Aside from P/D, the other most common surgical treatment option for pleural mesothelioma is an extrapleural pneumonectomy (EPP). Both are potentially curative, meaning the goal is to remove all tumors and extend life expectancy, and both involve the removal of tumors from the chest cavity and therefore have the best success rates when tumors have not spread to other organs in the body.
However, there are differences between a P/D and an EPP, including the extent of the procedure, the aggressiveness and the long-term effects.
P/D is a less radical procedure than EPP, because unlike in a P/D where the lining of the lung is removed, in an EPP an entire lung and its lining are removed. This means that in most cases when the cancer has spread to the lungs, an EPP can be performed, but not a P/D. The removal of a lung can decrease the chances of recurrence by removing parts of the tumor left on the lung that a P/D may not be able to remove, but it can also have a lasting impact on quality of life by permanently limiting physical activity. Although a P/D is associated with a better quality of life, it also increases the chances for recurrence.
EPP is more invasive and therefore it is also associated with more complications and risks. An EPP has a mortality rate of 7 percent while a P/D has a mortality rate of 4 percent.
Research shows that both options increase survival rates in patients. In one study of 663 patients, patients who underwent P/D had a better survival rate (16 months) than those who underwent EPP (12 months). However, the researchers in this study noted that survival rates are affected by other factors such as the stage of cancer, histological type of mesothelioma, age of the patient and other types of treatments received by the patient, and the result of the study does not necessarily indicate that P/D always leads to longer survival rates.
Considering the differences and the similarities of these two surgical options, a P/D may be more appropriate than an EPP when a patient is older, not as physically fit, has experienced slight cardiac problems and the tumor has not spread past the lining of the lungs.
However, a doctor will determine whether a P/D or EPP is right for the patient depending on the patient’s prognosis and other factors.
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