Surgery Options for Pleural Mesothelioma: Pleurectomy/Decortication vs. Extrapleural Pneumonectomy

Choosing a surgery for pleural mesothelioma is a careful, personal decision. Both pleurectomy/decortication (P/D) and extrapleural pneumonectomy (EPP) aim to remove cancer from the lining of the lung and chest. They differ in how much tissue is removed and how they affect breathing afterward.

P/D removes the diseased lining and visible tumor, while keeping the lung. EPP removes the lining, the lung on that side, and sometimes parts of the diaphragm and the heart lining, which are then rebuilt. Your team weighs tumor spread, lung function, and your goals. Asbestos exposure is the main cause of mesothelioma. Surgery is one part of care along with drug therapy and supportive treatment.

This guide reviews what each surgery involves, who may qualify, benefits and risks, recovery, and how to choose with your team. It is informational only. Discuss your options with a mesothelioma specialist.

What are Pleurectomy and Decortication and Extrapleural Pneumonectomy?

The pleura is a thin lining around the lungs and chest wall. In pleural mesothelioma, cancer grows on this lining. This can trap the lung, cause chest pain, and make breathing hard.

Pleurectomy and decortication, or P/D, removes the diseased pleura and visible tumor. Surgeons peel tumor from the lung surface and chest wall. The lung stays in place. The goal is to free the lung so it can expand and to reduce symptoms.

Extrapleural pneumonectomy, or EPP, removes more tissue. Surgeons remove the pleura and the entire lung on the affected side. If the tumor involves the diaphragm or the sac around the heart, they remove those parts too. They then rebuild the diaphragm and pericardium with patches. This helps the chest work after surgery.

Both surgeries have a shared aim. They try to remove as much tumor as possible to ease symptoms and allow other treatments, like chemotherapy or radiation, to work better. Surgeons may suggest one over the other based on where the tumor sits, how far it has spread, and how well your lungs and heart can handle the operation. Comparative studies review these choices and trends, including analyses in peer‑reviewed journals such as The Annals of Thoracic Surgery00846-8/fulltext) and PubMed summaries of surgical outcomes.

How Pleurectomy and Decortication works step by step

You receive anesthesia so you are asleep and pain free. The surgeon makes one or more incisions to enter the chest. They remove the diseased pleura and peel tumor from the lung surface and chest wall. The tight tumor rind is removed to let the lung expand again.

If the tumor involves the diaphragm or heart lining, the team can remove small areas and place a patch to repair them. The lung stays in place. Common goals include better breathing, less chest pain, and improved quality of life. P/D often takes several hours and is performed by teams with mesothelioma experience.

How Extrapleural Pneumonectomy works step by step

You receive general anesthesia. The surgeon makes an incision to open the chest. They remove the pleura and the entire lung on the affected side. If the tumor involves the diaphragm or pericardium, those parts are removed as well.

The team rebuilds the diaphragm and pericardium with patches so the chest can function. This is a larger operation and often needs a longer hospital stay. The aim is to remove all visible tumor when cancer wraps the lung or invades nearby structures in a way that P/D cannot address. Overviews for patients describe these key differences in plain terms, such as this resource on pleurectomy vs pneumonectomy.

Goals and when surgeons consider each option

Both surgeries share goals. Remove visible tumor, ease pain and shortness of breath, improve the fit for other therapies, and try to extend life.

P/D is often considered when the tumor can be peeled off and lung function is limited or needs to be preserved. EPP may be considered when the tumor fully encases the lung or grows into nearby tissues where lung removal may help achieve a more complete resection. The plan depends on scans, biopsy results, and fitness for surgery.

Key similarities and differences at a glance

• Similarities:
• Aim to remove tumor and relieve symptoms
• Major chest operations with recovery time
• Best done at centers with experience
• Often part of a multimodal plan with drug therapy and radiation
• Differences:
• P/D spares the lung; EPP removes the lung
• P/D may preserve more breathing capacity and shorten recovery
• EPP is more extensive and may carry higher risk of complications
• Selection depends on tumor spread and lung function

Who is a candidate for P/D vs EPP?

Candidacy rests on a careful review. Teams assess overall health, lung and heart function, tumor stage and pattern, and the mesothelioma cell type. The epithelioid type often responds better to surgery than sarcomatoid. Biphasic tumors vary based on the mix of cells. These features shape both the surgical plan and the expected recovery.

Doctors use imaging and breathing tests to guide the choice. They look for signs that the tumor is confined to one chest side. They check how the lung, heart, and muscles will handle the operation. Not everyone with pleural mesothelioma benefits from major surgery. Some patients do better with non-surgical care that focuses on symptom control and systemic therapy.

Shared decision making is important. Goals, values, and support at home all matter. Many teams discuss cases at a tumor board to weigh the details with thoracic surgeons, medical oncologists, radiation oncologists, and supportive care experts. Reviews of surgical series, such as those summarizing outcomes for P/D and EPP on PubMed, can help frame questions for your visit.

Tests that guide the decision

• CT scan and PET-CT: Map tumor spread, detect active disease, and check lymph nodes.
• MRI: Helps when the chest wall, diaphragm, or spine may be involved.
• Lung function tests: Measure airflow, volume, and gas exchange to see how the lungs perform.
• Heart tests: An echocardiogram or stress test if heart disease is possible.
• Blood tests: Check blood counts, kidney and liver function, and nutrition markers.
• Biopsy: Confirms mesothelioma and defines the cell type.
• Sometimes bronchoscopy or mediastinoscopy: Checks airway or lymph nodes if needed.

Each test helps match the operation to the tumor pattern and your fitness for surgery.

Tumor features that matter for surgery

Key features include whether disease stays on one side of the chest, whether it invades the chest wall, diaphragm, or lymph nodes, and the cell type. More limited disease and epithelioid type can increase the chance that surgery helps. When cancer spreads beyond the chest or when there is bulky nodal disease, EPP is less likely to benefit and non-surgical options may be better. Contemporary reports comparing operations, including large series in thoracic surgery journals, discuss these patterns.

Health factors and lung function needs

Age, heart disease, COPD, nutrition, and baseline activity level affect readiness. EPP removes one lung, so it requires stronger lung and heart function. P/D may fit better if lung function is reduced, since it preserves the lung. Prehab helps both paths. Walking, breathing exercises, and light strength work can improve fitness before surgery and may speed recovery.

Questions to ask your surgeon

• What is my stage and cell type?
• Am I a better fit for P/D or EPP, and why?
• What are the goals for me, symptom relief or maximal tumor removal?
• How many of these surgeries has your team performed?
• What are the risks in my case?
• How will this affect my breathing and daily life?
• What other treatments will I need before or after surgery?
• How long is the hospital stay and recovery?
• What support will I need at home?

What are the benefits, risks, and recovery for each option?

P/D can improve breathing by freeing a trapped lung. Many patients report less chest pressure and a better ability to walk and climb stairs. EPP may reduce tumor bulk when it fully encases the lung or invades nearby structures. It is a larger operation with higher risk and a longer recovery for many patients.

Common risks include bleeding, infection, air leaks, pneumonia, heart rhythm problems, and blood clots. Some patients have shoulder pain, nerve pain, or numbness near the incision. Fluid buildup can occur and sometimes needs drainage. Teams work to prevent complications with careful technique, early movement, and breathing support.

Recovery starts in the ICU or a step-down unit. You may have chest tubes, a urinary catheter, and IV lines. Pain control often includes an epidural or nerve blocks. Respiratory therapy guides breathing exercises and cough support. Walking starts early with help. Long term recovery includes pulmonary rehab, energy management, and a plan to resume daily tasks. Multiple comparative studies explore outcomes and tolerance profiles of P/D versus EPP, including systematic reviews that discuss trends over time.

Expected benefits and limits of P/D vs EPP

Both surgeries can relieve symptoms, improve lung expansion when possible, and offer a chance at more time when paired with other treatments. Surgery alone does not cure most cases of mesothelioma. Microscopic disease can remain, which is why multimodal care is common.

P/D preserves the lung, which may protect quality of life and activity level. EPP may offer broader tumor removal in select patients, but you live with one lung afterward. Some centers favor P/D for better tolerance, while others select EPP in specific cases. Ongoing debates appear in peer‑reviewed literature, like comparative analyses in The Annals of Thoracic Surgery00846-8/fulltext).

Common risks and complications to know

• Bleeding and transfusion needs
• Infections and pneumonia
• Prolonged air leak after P/D
• Heart rhythm problems after chest surgery
• Blood clots in the legs or lungs
• Pain, numbness, or nerve irritation near the incision
• Fluid buildup in the chest or abdomen
• Readmission for breathing or wound issues

EPP carries added risk due to lung removal and reconstruction of the diaphragm and pericardium. Ask your team about your personal risk, how they lower it, and what steps they take to prevent complications. Patient education sources, such as pleurectomy vs pneumonectomy overviews, can help frame these discussions.

Hospital stay and early recovery timeline

Expect care in the ICU or a step-down unit at first. Chest tubes drain fluid and air. Pain control may use an epidural or nerve blocks. You will do breathing exercises every hour while awake and start walking with help as soon as possible.

A typical path to home includes stable oxygen levels, removal of chest tubes, and manageable pain on pills. P/D hospital stays are often shorter than EPP due to the difference in the extent of surgery. The care team sets daily goals and teaches you how to continue breathing work and movement at home.

Rehab and long term recovery tips

• Join pulmonary rehab if available.
• Use the incentive spirometer at home as directed.
• Walk daily with a gradual plan.
• Space activities, and rest before you feel spent.
• Focus on protein rich meals and hydration.
• Keep a sleep routine, and talk about mood changes early.
• Ask for caregiver help and social work support.
• Return to driving and work only after your surgeon clears you.

How to choose the right path with your care team

A good plan matches clinical facts with personal goals. Start with shared decision making. Your team will review scans, biopsies, and lung and heart tests. Discuss what matters most to you, such as breathing comfort, time at home, or aggressive tumor control.

Seek care at high volume centers with mesothelioma programs. Experience matters for results, ICU support, and rehab. Ask for a second opinion to compare P/D and EPP plans. Many teams combine surgery with chemotherapy, targeted radiation, and sometimes immunotherapy, as part of a multimodal plan. For an overview of standard options, see these mesothelioma treatment options. Tumor boards often guide sequencing.

Clinical trials may expand choices, including novel drug regimens and perioperative strategies. Evidence continues to evolve, and several comparative studies, such as Flores et al., discuss selection and outcomes across operations. Consider costs, insurance approvals, and travel logistics. Ask about supportive resources, housing near the hospital, and return-to-work planning. For legal questions related to asbestos exposure and to make a claim, you can contact Danziger & DeLlano LLP at www.dandell.com.

Questions that match treatment to your goals

• What matters most to me, breathing comfort, time at home, or aggressive tumor control?
• What trade offs am I willing to accept?
• How far am I able to travel for care?
• Who can help me during recovery?
• What plan best fits my work and family needs?

Why high volume centers and second opinions matter

Outcomes are often better when teams perform these operations often. Ask about surgeon and hospital experience with P/D and EPP, ICU staffing, and rehab services. A second opinion from another mesothelioma program can confirm the plan or offer options you have not considered. Some centers publish their approaches and selection criteria, and current comparative reports, including recent thoracic surgery analyses, can guide informed questions during consultations.

How surgery fits with chemo, radiation, and immunotherapy

Many patients receive chemotherapy before or after surgery. Some may receive targeted radiation to the chest to reduce local tumor. Immunotherapy may be used in certain cases based on cell type and trial access. A tumor board often reviews the sequence to match the biology and the recovery plan. Ask when each part happens, how they interact, and what side effects to expect. Reviews that compare multimodal strategies, like recent summaries in thoracic surgery literature, can support these discussions.

Costs, insurance, and support resources

Speak with a financial counselor early. Confirm insurance coverage, prior approvals, and travel support if needed. Ask about patient lodging near the hospital and caregiver resources. Look into disability or leave options at work. Social workers can help with home care, equipment, and community support. For legal guidance related to asbestos exposure, you can reach Danziger & DeLlano LLP at www.dandell.com.

Conclusion

P/D preserves the lung and may protect breathing and daily function. EPP removes more tissue and may suit certain patterns of tumor spread. The best choice depends on imaging, health, and your goals. A thoughtful plan can help manage asbestos, mesothelioma related disease with care that fits your life.

Next steps: gather your records and scans, write your questions, ask about P/D and EPP at a high volume center, request a second opinion, and discuss clinical trials. To explore treatment paths alongside surgery, see expert summaries such as comparative outcomes in peer‑reviewed reviews. For help with claims related to asbestos exposure, contact Danziger & DeLlano LLP at www.dandell.com. Seek guidance from a mesothelioma specialist, and build a plan that aligns with your values.