Pleurectomy and Decortication

P/D Surgical Profile
Lung-Sparing Cytoreductive Surgery
Category	Medical / Surgical Treatment
Procedure Type	Thoracic Surgery (Inpatient)
Anesthesia	General
Duration	4–6 hours
Hospital Stay	7–14 days typical
30-Day Mortality	0–3.4% (high-volume centers)
Goal	Macroscopic Complete Resection (MCR)
Key Trial	MARS 2 (Phase 3 RCT)
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Pleurectomy/decortication (P/D) is a lung-sparing surgical procedure for malignant pleural mesothelioma (MPM) that removes the diseased pleural lining and all visible tumor while preserving the underlying lung. The procedure is performed under general anesthesia by a specialized thoracic surgeon and typically takes 4–6 hours. Over the past two decades, P/D has largely supplanted the more radical extrapleural pneumonectomy (EPP), which removes the entire lung, as centers worldwide have recognized that lung-sparing approaches achieve comparable or superior survival with significantly lower morbidity and mortality.

The procedure exists in two forms: standard P/D, which removes the parietal and visceral pleura, and extended P/D (EPD), which additionally includes resection and reconstruction of the diaphragm and/or pericardium. The goal of both is macroscopic complete resection (MCR) — removal of all visible tumor. When combined with adjuvant therapies such as chemotherapy, radiation, or hyperthermic intrathoracic chemotherapy (HITHOC), P/D forms a cornerstone of multimodal treatment for resectable mesothelioma.

The 2023 MARS 2 trial introduced significant controversy by reporting that extended P/D was associated with worse survival compared to chemotherapy alone, though critics have noted that the trial's 9% 90-day surgical mortality rate far exceeds the 0–4.2% rates achieved at high-volume centers — underscoring the importance of selecting experienced mesothelioma surgical teams.

Pleurectomy and decortication at a glance:

• Two P/D variants — standard P/D removes parietal and visceral pleura; extended P/D additionally resects and reconstructs the diaphragm and pericardium
• MARS 2 trial results — 335-patient RCT reported 9% 90-day surgical mortality and worse 2-year survival for extended P/D plus chemotherapy versus chemotherapy alone
• High-volume center contrast — Mount Sinai 71-patient series showed 0% 30-day mortality and 4.2% 90-day mortality during the same enrollment period as MARS 2
• MCR survival advantage — patients achieving macroscopic complete resection had median survival of 28.2 months versus 13.1 months for incomplete resection (p < 0.0001)
• HITHOC combination — adding heated intrathoracic chemotherapy extends median survival from 11–22.8 months to 13–35 months across 7 studies
• Perioperative mortality — 0–3.4% at experienced centers versus historically higher rates for EPP, with lower empyema, hemorrhage, and atrial fibrillation rates
• Most common complication — prolonged air leak occurs in 7.1–23.5% of P/D patients, a complication unique to the lung-sparing approach
• Candidacy requirements — FEV1 at least 50% predicted, DLCO at least 50% predicted, ECOG 0–1, and resectable disease at stages I–IIIA
• Recovery timeline — 7–14 day hospital stay with 1–3 days in ICU; full recovery to near-baseline activity at 3–6 months
• Lung preservation benefit — P/D maintains postoperative pulmonary function, with improvement continuing up to 6 months after surgery

Key Facts

Key Facts: Pleurectomy and Decortication (P/D)

Procedure: Lung-sparing surgery that removes the diseased pleural lining (pleurectomy) and visible tumor from the lung surface (decortication) Standard P/D vs. Extended P/D: Standard removes parietal and visceral pleura; extended additionally resects diaphragm and/or pericardium with reconstruction EPP Comparison: EPP removes the entire lung plus pleura, diaphragm, and pericardium — P/D preserves lung function with lower perioperative mortality 30-Day Mortality (High-Volume): 0–3.4% for P/D versus higher rates historically reported for EPP MARS 2 Trial (2023): First randomized trial of EPD; reported surgery associated with worse 2-year survival (335 patients randomized) Mount Sinai Response: 71-patient contemporaneous series showed 0% 30-day and 4.2% 90-day mortality, emphasizing volume-dependent outcomes HITHOC Addition: Heated intrathoracic chemotherapy (cisplatin, 40–43°C, 60–70 minutes) added after P/D may extend median survival from 11–22.8 months to 13–35 months MCR Survival Benefit: Patients achieving macroscopic complete resection had median survival of 28.2 months versus 13.1 months for incomplete resection (p < 0.0001) Patient Selection: Requires FEV1 ≥ 50% predicted, DLCO ≥ 50% predicted, ECOG 0–1, and resectable disease (stages I–IIIA) Most Common Complication: Prolonged air leak (7.1–23.5%) — unique to lung-sparing P/D Hospital Stay: Typically 7–14 days; ICU monitoring for first 1–3 days Full Recovery: 3–6 months to near-baseline activity; pulmonary function may continue improving for up to 6 months

What Is Pleurectomy and Decortication?

Pleurectomy/decortication (P/D) is one of two primary surgical approaches for resectable malignant pleural mesothelioma. The procedure involves two distinct steps performed in sequence during a single operation:

Pleurectomy: The surgeon removes the diseased parietal pleura (the membrane lining the chest wall) and the visceral pleura (the membrane covering the lung surface). This is the structural removal that strips away the primary tumor-bearing tissue.

Decortication: The surgeon then removes all visible tumors, fibrous tissue, and affected tissue from the lung surface and surrounding structures. The goal is to free the lung so it can fully re-expand within the chest cavity.

What Is the Difference Between Standard P/D and Extended P/D?

The two main variants differ in their extent of resection:

Feature	Standard P/D	Extended P/D (EPD)
Pleura Removal	Parietal and visceral pleura	Parietal and visceral pleura
Diaphragm	Preserved	Resected and reconstructed
Pericardium	Preserved	Resected and reconstructed
Lung	Preserved	Preserved
Goal	Tumor debulking / MCR	Macroscopic complete resection (MCR)

How Does P/D Compare to Extrapleural Pneumonectomy (EPP)?

Extrapleural pneumonectomy (EPP) is the more radical alternative, removing the entire affected lung along with the pleura, diaphragm, and pericardium. The shift from EPP to P/D has been one of the most significant trends in mesothelioma surgery over the past two decades:

• P/D preserves lung function, reducing the physiological impact on the patient
• P/D has significantly lower perioperative mortality (0–3.4% vs. historically higher rates for EPP)
• Lapidot et al. (Annals of Surgery, 2022) analyzed 355 P/D patients and found epithelioid patients with MCR achieved superior overall survival compared to large EPP cohorts
• Major centers including Memorial Sloan Kettering, Brigham and Women's Hospital, and leading European institutions have shifted from EPP to P/D-based approaches
• P/D has lower rates of empyema, atrial fibrillation, hemorrhage, and bronchopleural fistula compared to EPP

What Did the MARS 2 Trial Show?

The Mesothelioma and Radical Surgery 2 (MARS 2) trial was the first randomized controlled trial comparing extended pleurectomy decortication plus chemotherapy versus chemotherapy alone for resectable pleural mesothelioma. Its results, presented at the Presidential Plenary of the 2023 World Conference on Lung Cancer, generated substantial controversy within the mesothelioma surgical community.

Trial Design and Results

Parameter	Detail
Design	Phase 3 randomized controlled trial
Enrollment	335 patients (169 surgery + chemotherapy, 166 chemotherapy alone)
Lead Investigator	Eric Lim, MB ChB, MD — Royal Brompton Hospital / Imperial College London
Key Finding	EPD was associated with worse survival to 2 years and more serious adverse events
90-Day Surgical Mortality	9% in the surgery arm
Investigator Statement	Dr. Lim stated surgery cessation would increase survival by 28% for these patients

Why Is MARS 2 Controversial?

The MARS 2 results generated significant debate because the 9% 90-day mortality rate observed in the surgery arm was considerably higher than rates reported by high-volume mesothelioma surgical centers. A contemporaneous Mount Sinai series led by Dr. Raja Flores analyzed 71 patients undergoing P/D between 2015–2021 — the same enrollment period as MARS 2 — and found strikingly different outcomes:

• 30-day mortality: 0% (compared to the overall surgical mortality pattern in MARS 2)
• 90-day mortality: 4.2% (compared to 9% in MARS 2)

This difference underscores a critical point: surgical outcomes for mesothelioma are highly volume-dependent and center-dependent. The implication is not necessarily that P/D should be abandoned, but rather that it should be performed only at centers with established expertise and high case volumes. The debate continues between those who interpret MARS 2 as evidence against surgery and those who view it as evidence for centralizing surgical care.

What Is HITHOC and How Does It Enhance P/D?

HITHOC (Hyperthermic Intrathoracic Chemotherapy) involves the perfusion of heated chemotherapy solution directly into the pleural cavity immediately after cytoreductive surgery (P/D or EPD). The concept is analogous to HIPEC (heated intraperitoneal chemotherapy) used in peritoneal cancers, and aims to destroy residual microscopic tumor cells that surgery alone cannot remove.

What Is the Standard HITHOC Protocol?

Parameter	Standard Protocol
Drug	Cisplatin (80–125 mg/m²), sometimes combined with doxorubicin
Vehicle	2 liters saline
Temperature	40–43°C (104–109°F)
Duration	60–70 minutes of continuous perfusion

What Does the Evidence Show for HITHOC?

Multiple studies and meta-analyses support the addition of HITHOC to cytoreductive surgery:

• Meta-analysis (2017): HITHOC after surgery significantly prolonged median survival compared to surgery alone (Hedges' g = 0.384 ± 0.105, 95% CI: 0.178–0.591, p < 0.001). HITHOC was also favored for recurrence-free interval (Hedges' g = 0.591, p < 0.001)
• Systematic review (2025): Six of seven studies demonstrated a survival benefit for HITHOC; median survival ranged from 13–35 months with HITHOC versus 11–22.8 months without. No HITHOC-related mortality was reported across all studies
• P/D + HITHOC series (2019): 71 patients; epithelioid subtype median survival 17.9 months; patients achieving MCR had median survival of 28.2 months versus 13.1 months for incomplete resection (p < 0.0001)
• Comparative study (2024): 55 patients; HITHOC group (cisplatin 125 mg/m², 70 min, 40–43°C) vs. surgery only; 30-day mortality 0% (HITHOC) versus 3.3% (surgery only)

What Are the Renal Safety Concerns with HITHOC?

Because cisplatin is nephrotoxic, renal safety during HITHOC is closely monitored. A multicenter study of 350 patients found that patients receiving high-dose cisplatin were 2.7 times more likely to suffer renal insufficiency than those receiving low-dose cisplatin (p = 0.006). However, overall rates remained within clinically acceptable ranges. Transient complications from HITHOC (reported in approximately 16% of patients) include atrial fibrillation, renal impairment, and transient hypotension — all of which are typically manageable.

Who Is a Candidate for P/D Surgery?

Patient selection for P/D is determined through a multidisciplinary evaluation that considers pulmonary function, overall health, and disease extent. The decision to proceed with surgery must be made by a multidisciplinary treatment conference consisting of mesothelioma surgeons, radiologists, pathologists, medical oncologists, and palliative care physicians.

What Are the Pulmonary Function Requirements?

Parameter	Threshold	Notes
FEV1	≥ 50% predicted	FEV1 < 50% is an exclusion criterion (per NCT07126509)
DLCO	PPO-DLCO ≥ 50% predicted	PPO-DLCO of 40% identified as best predictor of postoperative respiratory failure
PPO-FEV1 and PPO-DLCO > 60%	No further testing needed	Per ERS/ESTS guidelines — surgery can proceed
PPO values 30–60%	Low-technology exercise testing	If VO₂max > 20 mL/kg/min (or > 75% predicted), surgery can proceed
ECOG Status	0–1	NYHA Functional Class 2B or better for cardiac risk

What Other Criteria Must Be Met?

• Staging: Resectable disease, typically stages I–IIIA per current staging guidelines
• Histology: Epithelioid subtype has the best surgical outcomes; sarcomatoid histology is generally not recommended for surgery
• No uncontrolled intercurrent illness
• No active prior malignancy within 2 years (except curable cancers such as basal cell skin cancer)
• Cardiac assessment: NYHA Functional Classification class 2B or better

What Are the Complication Rates After P/D?

A comprehensive literature review of P/D outcomes across 12 published series (2008–2015) provides detailed complication data. While P/D has lower mortality than EPP, it carries a unique complication profile related to preserving the lung:

Complication	Rate Range	Notes
30-Day Mortality	0.0–6.8%	Most high-volume series report 0–3.4%
Prolonged Air Leak	7.1–23.5%	Most common P/D complication — unique to P/D (not seen in EPP)
Arrhythmia (A-fib/SVT)	2.3–21.4%	Most frequently supraventricular tachycardia
Respiratory Failure	2.3–7.1%	Major complication requiring ventilatory support
Bleeding/Hemorrhage	0.0–16.7%	Varies widely by series
Pneumonia	4.5–25%	Aspiration pneumonia is a major concern
DVT/VTE	4.5–28.6%	Higher rates in some series
Overall Complication Rate	9.0–43.0%	Broad range depending on center experience

How Can Complications Be Reduced?

A 2023 Mount Sinai series identified aspiration pneumonia, DVT, and line sepsis as the primary drivers of P/D morbidity and demonstrated that implementing four targeted strategies significantly reduced these complications:

• Early tracheostomy when prolonged intubation is anticipated
• Therapeutic anticoagulation initiated at diagnosis
• Gastrostomy placement to prevent aspiration events
• Jejunostomy tube placement for nutritional support

A meta-analysis (2022) confirmed that P/D has significantly lower rates of empyema, atrial fibrillation, hemorrhage, and bronchopleural fistula compared to EPP. However, prolonged air leak remains more common with P/D because the lung-sparing approach leaves raw lung surface exposed. Postoperative empyema, when it occurs, is associated with prolonged length of stay and higher mortality — making strategies to minimize prolonged air leak critical.

What Is the Recovery Timeline After P/D?

Recovery from pleurectomy/decortication follows a staged progression. Individual timelines vary based on the extent of surgery, patient fitness, and whether complications occur:

Phase	Timeline	Key Milestones
ICU Monitoring	Days 1–3	Chest tubes in place; epidural or IV pain management; respiratory function, oxygen saturation, and hemodynamic monitoring
Step-Down Unit	Days 3–7	Transfer from ICU if stable; gradual mobilization; chest tube drainage monitored (removal when < 200–300 mL/day with no air leak)
Pre-Discharge	Weeks 1–2	Most chest tubes removed by days 7–14; prolonged air leak (>5 days) may delay discharge; incentive spirometry begins; hospital discharge at 7–14 days
Early Home Recovery	Weeks 2–6	Gradual increase in walking; avoid lifting >10 lbs; transition to oral pain medications; follow-up chest X-rays at 2 and 6 weeks
Rehabilitation Phase	Weeks 6–12	Return to light daily activities; pulmonary rehabilitation may begin; adjuvant chemotherapy or radiation may start at 4–8 weeks post-surgery
Full Recovery	3–6 months	Gradual return to near-baseline activity; surveillance imaging (CT every 3–6 months); pulmonary function may continue improving up to 6 months

Where Are the High-Volume P/D Centers?

Volume-outcome relationships in mesothelioma surgery are well established — higher-volume centers consistently report lower mortality rates, fewer complications, and better long-term survival. Patients considering P/D should seek evaluation at a center with a dedicated mesothelioma surgical program:

• Memorial Sloan Kettering / Mount Sinai (New York): Dr. Raja Flores — reported a 71-patient P/D series with 0% 30-day mortality and 4.2% 90-day mortality, a benchmark for surgical excellence
• Brigham and Women's Hospital (Boston): Historically the home of Dr. David Sugarbaker's EPP program; has shifted toward P/D-based approaches. Now also linked to Baylor College of Medicine
• Royal Brompton Hospital / Imperial College London: Dr. Eric Lim — led the MARS 2 trial, one of the most experienced European mesothelioma surgical programs
• University of Pennsylvania: Dr. Joseph Friedberg — pioneer of photodynamic therapy combined with P/D
• MD Anderson Cancer Center (Houston): High-volume thoracic surgery center with a dedicated mesothelioma specialization
• National Cancer Institute (Bethesda): Active mesothelioma surgical program within the NCI clinical center

"Mesothelioma surgery is not a procedure where any thoracic surgeon will do. The difference between a high-volume center and a low-volume one can mean the difference between a 0% and a 9% surgical mortality rate. Patients deserve to know that the surgeon's experience directly impacts their outcome."

— David Foster, Patient Advocate, Danziger & De Llano

What Is the History of Pleurectomy and Decortication?

The evolution of P/D reflects broader trends in surgical oncology toward less radical, organ-preserving approaches:

• 1940s: Surgery to remove the pleural lining (pleurectomy) first described for treatment of pleural disease
• 1960s: Pleurectomy combined with decortication (removal of fibrous tissue from the lung surface) began to appear in the surgical literature
• 1976: Butchart and colleagues described the extrapleural pneumonectomy (EPP) technique, which became the dominant radical approach for decades
• 1990s–2000s: Growing evidence that P/D achieved comparable survival to EPP with lower morbidity prompted a gradual shift in surgical practice
• 2004: The original MARS feasibility trial raised questions about the benefit of EPP
• 2010s: Multiple retrospective series demonstrated excellent outcomes for P/D at high-volume centers; extended P/D with diaphragm and pericardial reconstruction became more standardized
• 2023: The MARS 2 trial reported that extended P/D was associated with worse survival versus chemotherapy alone, intensifying debate about patient selection and center volume
• Present: The goal has evolved toward macroscopic complete resection (MCR); robotic-assisted techniques are increasingly used for greater precision; the role of perioperative immunotherapy combined with surgery is actively being studied in clinical trials

What Are the Cost and Access Considerations?

P/D is a complex, resource-intensive procedure that requires specialized surgical teams, prolonged hospitalization, and often multimodal adjuvant therapy. Several factors affect patient access:

• Geographic access: High-volume mesothelioma surgical centers are concentrated in a small number of academic medical centers. Many patients must travel significant distances for evaluation and surgery
• Insurance coverage: P/D for mesothelioma is generally covered by Medicare and major insurance plans when deemed medically appropriate by a multidisciplinary team
• Total cost: The combination of surgery, ICU care, 7–14 day hospitalization, and adjuvant therapy represents a substantial total treatment cost, though specific figures vary widely by center and extent of surgery
• Lost wages and caregiver burden: The 3–6 month recovery period affects both patients and their families financially and personally
• Legal compensation: Many mesothelioma patients qualify for compensation through asbestos trust funds, VA benefits (for veterans with service-related exposure), or legal claims that can help offset treatment costs
• Second opinions: Given the controversies highlighted by MARS 2, patients are strongly encouraged to obtain a second surgical opinion from a high-volume center before committing to — or declining — surgery

Related Resources

• Mesothelioma Surgery Overview
• Mesothelioma Surgery Recovery
• Heated Chemotherapy (HITHOC and HIPEC)
• Mesothelioma Biopsy Procedures
• Immunotherapy for Mesothelioma
• Mesothelioma Diagnosis and Staging
• Mesothelioma Types
• Treatment Options
• Clinical Trials

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