For More Information: Contact Us

Mesothelioma Treatments: Curative Surgery - Pleurectomy-Decortication

Pleurectomy-decortication is a compound surgery, featuring a parietal pleurectomy and a decortication of the lung with a full resection of visceral pleura. During a pleurectomy-decortication both pleurae will be removed and it is likely that extrapleural tissue structures, such as parts of the diaphragm and the pericardium, will be removed as well. It is commonly deployed for patients presenting with the earliest stages of the disease, although the individual procedures can be deployed for palliative purposes as well. To learn more about these palliative uses, please read:

Pleurectomy-decortication is one of the two major curative surgeries performed for the treatment of pleural mesothelioma. Extrapleural pneumonectomy (EPP) is the other major surgery.

Pleurectomy-Decortication – Overview of the Procedure

Pleurectomy-decortication (PD) is considered radical surgery due to the extensive amount of tissue resection attempted during the procedure and the highly invasive techniques necessary to complete the operation. Patients who undergo pleurectomy-decortication face an extended recovery period and serious complications are not uncommon, but the procedure has been used to extend survival time in large numbers of mesothelioma patients.

During the earliest phases of the operation, pleurectomy-decortication and extrapleural pneumonectomy proceed in a similar manner. The procedure requires an extended posterolateral thoracotomy for entry into the interior of chest. The extensive incision is done to give the surgeon greater exposure to the patient’s thorax. In some cases, the 6th rib may be removed to facilitate entry into the pleural cavity. When the surgeon reaches this area, he or she will then begin the actual resection.

The parietal pleura and its surrounding areas will be the surgeon’s initial target. The diaphragm is likely to be removed, as is the pericardium if it cannot be easily separated from the parietal pleura or if it shows any signs of malignancy.

The surgeon will then begin what is probably the most difficult part of the operation: decortication of the lung and full resection of the visceral pleura. A number of issues can affect the degree to which the two pleurae can be separated and the visceral pleura cleanly and safely removed from the lung, so the surgeon will carefully analyze the status of these tissue structures and will proceed in a manner that maximizes the potential for full removal of the visceral pleura and the achievement of a macroscopically-complete resection. Any surgical manipulation of the visceral pleura raises the possibility for damage to the underlying lung, so the surgeon must balance the desire to achieve full resection with the present status of the lung and the potential for attendant lung damage.

After the surgeon has completed the operation, he or she must then begin the reconstructive processes which are necessary to ensure proper lung function. If the diaphragm or the pericardium has been removed, the surgeon will reconstruct the respective structure using a mesh fiber that will achieve a similar function as the original structure.

During the procedure, the surgeon will remove adjacent lymph nodes for post-operative staging analysis. The lymph nodes will be packaged and identified, and then sent to a pathologist for analysis. This information will inform whatever follow-up treatments that the patient may undergo.

Once all of the tissues have been removed, and the diaphragm and pericardium reconstructed if needed, the surgeon will begin the exit procedure. Complications are not uncommon with pleurectomy-decortication, so the surgeon will check to make sure that everything has been properly completed and is in the appropriate state. Drainage tubes will be inserted in various locations to ensure fluid dissemination from the pleural cavity and surrounding areas. This should enable proper lung expansion and will aid in patient recovery. Should everything be order, the surgeon will step backward through each of the steps made during the initial approach, reconstructing and reattaching tissues that had to be cut during entry and closing up incisions as he or she goes along.

The patient will then be moved into the Intensive Care Unit for a few days of monitoring before starting on his or her rehabilitation program. Pleurectomy-decortication and thoracotomy are major operations and feature significant post-operative healing, so it is important for patients to take their recovery slowly.

Pleurectomy-Decortication – Treatment Considerations

As in all forms of radical surgery, serious complications can occur during pleurectomy-decortication, or the hours and days immediately following it. Damage to the lung from manipulation of the visceral pleura is always a concern, as are complications related to blood loss, breathing obstructions and the reconstruction of the diaphragm and pericardium. However, despite the possibility for complications, most surgeons feel that candidates for curative surgery should undergo the operation to maximize their potential for long-term survival. Most of the complications associated with pleurectomy-decortication are now fairly well-known, so even if surgeons aren’t able to prevent their occurrence, they can plan for their possibility and will be ready to adjust should one appear.

Historically, pleurectomy-decortication has demonstrated lower perioperative and postoperative mortality rates and morbidity figures than has extrapleural pneumonectomy.

Pleurectomy-Decortication vs. Extrapleural Pneumonectomy

A recurrent question in mesothelioma treatment is to what extent pleurectomy-decortication should be chosen over extrapleural pneumonectomy and what it “means” to choose one procedure over the other. Many people have thought that the treatments were relatively interchangeable and that pleurectomy-decortication was the “better” option for the treatment of pleural mesothelioma because it is a less radical procedure that preserves the lung, while extrapleural pneumonectomy was the “worse” option because of the removal of the long and the extended recovery time.

Studies have generally concluded that the two procedures have different domains of application and are most effective for patients in different stages of the disease. Pleurectomy-decortication is generally performed on patients who present with locally-contained mesothelioma that only evidences a sparse advancement into adjacent tissues, while extrapleural pneumonectomy is most-often used for patients who exhibit more extensive spread of the disease or for those who have enrolled in a treatment protocol that specifies EPP as one modality in a multimodal approach to the disease.

The key to all mesothelioma surgeries is to achieve a macroscopically-complete resection, so the procedure that can best achieve such a resection is in fact “the better” procedure for an individual patient. During the disease’s earliest stages, a pleurectomy-decortication may be all that is needed to achieve a macroscopically-complete resection. For patients who are lucky enough to be diagnosed with limited tumor burden, pleurectomy-decortication is likely to be a good option. However, for patients who present with more extensive tumor infiltration—the norm with the majority of mesothelioma diagnoses—extrapleural pneumonectomy will the surgery of choice because it is more likely to achieve a macroscopically-complete resection than is a pleurectomy-decortication.

In many instances, a surgeon will not know which procedure will be performed upon beginning thoracotomy. If preoperative imaging scans show only sparse tissue infiltration, the surgeon may assume that pleurectomy-decortication will be performed, but if, upon entry into the pleural cavity, it is discovered that CT or MRI failed to disclose the full extent of the malignancy, the surgeon will likely attempt an extrapleural pneumonectomy. Although less likely, the opposite could be true as well: the surgeon may begin thoracotomy with the assumption of extensive tissue infiltration and, therefore, the performance of an EPP, but upon entry into the pleural cavity, the surgeon may see a smaller area of infiltration and a PD will be performed instead.

Pleurectomy-Decortication – Conclusion

Pleurectomy-Decortication is one of the major surgeries employed for the treatment of pleural mesothelioma. Pleurectomy-decortication is performed on patients in the earliest stages of mesothelioma, when tissue infiltration is still relatively contained within a smaller surface area. Extrapleural pneumonectomy has probably been performed more than pleurectomy-decortication has been performed, so most of the results that relate to the multimodal treatment of the disease are reporting on EPP-based treatment protocols. However, successful pleurectomy-decortication should still achieve the same basic goal as a successful EPP—that is, a macroscopically-complete resection—so the use of pleurectomy-decortication within a multimodal treatment protocol is likely to achieve longer median survival than is a strictly palliative protocol or one that only features single modality therapy.

Related Information: Mesothelioma & Surgery

For more information related to the surgical treatment of mesothelioma, please read the following:

Our staff is available to answer your questions, point you in the right direction or provide additional information. Feel free to submit questions or comments below.

Name:

Phone:

Email:

Summary: