There are two surgical approaches to treat malignant pleural mesothelioma: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). One of the critical decisions a surgical oncologist must make is which of these approaches to choose. P/D may offer improved quality of life and has fewer immediate complications. EPP is more invasive but must be considered if the cancer has spread to the lung. 

P/D vs. EPP: An Overview 

The primary difference between the procedures is EPP comes with increased risks and complications due to the affected lung being entirely removed. It has a more substantial and detrimental effect on the patient’s quality of life. It is also considerably more invasive. Statistically, the mortality rate of EPP from the time of surgery till the end of the 30-day recovery period is approximately double that of P/D. There is also a permanent reduction in a patient’s stamina after EPP that must be considered before pursuing this treatment. 

Neither surgery is appropriate if the individual is too ill to withstand or recover from surgery or if the disease has spread beyond the lungs. If this spread has occurred, surgery is unlikely to result in significant improvement, and palliative care is the appropriate therapy to pursue. 

Survival Rates

When combined with other forms of treatment, both EPP and P/D can improve survival for malignant pleural mesothelioma. Certain studies show a longer survival time for patients undergoing P/D than EPP. The best survival outcomes occur when surgery is combined with other treatments, such as chemotherapy, radiation therapy, and immunotherapy. The external factors that oncologists must consider when recommending a treatment plan (e.g., age, cancer stage, cell type, and other treatment courses currently being used) can also have an impact on survival.

A 2013 systematic review evaluated the safety and effectiveness of P/D. The risk of death ranged from 0-11%. The risk of non-fatal complications ranged from 13-43%. The median overall survival ranged from 7.1-31.7 months, with 6-16 of those months being free of disease.¹

Over the years, the safety of P/D has improved. A 2017 literature review cites a thirty-day mortality rate of 0-6.8%. Concerning non-fatal complications, the most common major complications were bleeding (0-16.7%) and respiratory failure (2.3-7.1%). Minor complications included heart rhythm abnormalities (2.3-21.4%) and prolonged air leaks (7.1-23.5%).

EPP is considered to have a similar overall survival rate and a greater rate of death and non-fatal complications than P/D. A 2010 systematic review found the survival rate ranged from 9.4-27.5 months, the risk of death ranged from 0-11.8%, and the risk of non-fatal complications ranged from 22-82%. Not surprisingly, P/D is associated with a better quality of life than EPP. As a result, surgical oncologists prefer P/D over EPP unless the cancer has spread to the lung itself.²

Deciding Which Surgery Is Best 

The decision between EPP and P/D is heavily influenced by the medical needs and preferences of the patient. Many surgeons are naturally drawn to one approach over the other, due to their comfort level with performing the surgery. The patient’s cancer center and surgical oncologist often play a big role in which surgery the patient is likely to undergo.

After a patient has been declared a suitable candidate for surgery, one of the first considerations that the surgeon must make is regarding the number of tumors and their sizes and locations. If the cancer is only present in the lining of the lung, then P/D may well be all that is required, but if it has spread into the main bulk of the lung, then the surgeon may well recommend EPP instead to ensure a greater chance of successful resection. 

Mesothelioma treatment relies heavily on imaging technology to identify and scan tumors and determine the rate and extent of the cancer’s growth. Despite the accuracy of these scans, many surgeons will wait to decide which surgical approach to choose till after opening the chest cavity and assessing the situation directly. The surgeon can begin with the intent of performing one surgery, then, having made his or her observations and assessment, switch to the other. Both approaches can favorably impact a patient’s condition and overall quality of life, making them powerful tools in a surgeon’s arsenal when tackling malignant pleural mesothelioma.³