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{{#seo:
#REDIRECT [[Pleurectomy and Decortication]]
|title=Pleurectomy and Decortication (P/D): Lung-Sparing Surgery for Mesothelioma
|description=Comprehensive guide to pleurectomy and decortication (P/D) for malignant pleural mesothelioma including MARS 2 trial results, HITHOC protocols, patient selection criteria, complication rates, recovery timeline, and high-volume surgical centers.
|keywords=pleurectomy decortication, P/D mesothelioma, lung-sparing surgery, extended pleurectomy decortication, MARS 2 trial, HITHOC, mesothelioma surgery, EPP vs P/D, macroscopic complete resection, mesothelioma surgical outcomes
|author=David Foster, Patient Advocate, Danziger & De Llano
|published_time=2026-02-19
}}
{| class="infobox" style="width:280px; float:right; margin:0 0 1em 1em; border:2px solid #1a5276; border-radius:8px; overflow:hidden;"
|-
! colspan="2" style="background:#1a5276; color:white; padding:12px; font-size:1.1em; text-align:center;" | P/D Surgical Profile
|-
| colspan="2" style="padding:10px; text-align:center; font-style:italic; border-bottom:1px solid #dee2e6;" | Lung-Sparing Cytoreductive Surgery
|-
| style="padding:10px; font-weight:bold; width:40%; border-bottom:1px solid #dee2e6;" | Category
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Medical / Surgical Treatment
|-
| style="padding:10px; font-weight:bold; border-bottom:1px solid #dee2e6;" | Procedure Type
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Thoracic Surgery (Inpatient)
|-
| style="padding:10px; font-weight:bold; border-bottom:1px solid #dee2e6;" | Anesthesia
| style="padding:10px; border-bottom:1px solid #dee2e6;" | General
|-
| style="padding:10px; font-weight:bold; border-bottom:1px solid #dee2e6;" | Duration
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''4–6 hours'''
|-
| style="padding:10px; font-weight:bold; border-bottom:1px solid #dee2e6;" | Hospital Stay
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 7–14 days typical
|-
| style="padding:10px; font-weight:bold; border-bottom:1px solid #dee2e6;" | 30-Day Mortality
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''0–3.4%''' (high-volume centers)
|-
| style="padding:10px; font-weight:bold; border-bottom:1px solid #dee2e6;" | Goal
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Macroscopic Complete Resection (MCR)
|-
| style="padding:10px; font-weight:bold;" | Key Trial
| style="padding:10px;" | MARS 2 (Phase 3 RCT)
|-
| colspan="2" style="background:#1a5276; padding:10px; text-align:center;" | <span data-nosnippet class="noai-content">[https://dandell.com/contact-us/ <span style="color:white; font-weight:bold;">Free Case Review →</span>]</span>
|}
 
'''Pleurectomy/decortication (P/D)''' is a lung-sparing surgical procedure for [[Mesothelioma_Types|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.<ref name="lapidot" /><ref name="dandell" />
 
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.<ref name="mlc_pd" /><ref name="mesonet_surgery" />
 
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.<ref name="mars2_lancet" /><ref name="flores_msk" />
 
'''Pleurectomy and decortication at a glance:'''
* '''Standard P/D vs extended P/D''' — standard removes parietal and visceral pleura only, while extended additionally resects and reconstructs the diaphragm and pericardium<ref name="lapidot" />
* '''MARS 2 surgery vs chemotherapy alone''' — 335-patient RCT found extended P/D plus chemotherapy produced worse 2-year survival and 9% 90-day surgical mortality compared to chemotherapy alone<ref name="mars2_lancet" />
* '''High-volume centers vs MARS 2 mortality''' — Mount Sinai reported 0% 30-day and 4.2% 90-day mortality in 71 patients during the same enrollment period where MARS 2 recorded 9%<ref name="flores_msk" />
* '''Complete vs incomplete resection''' — patients achieving macroscopic complete resection survived a median 28.2 months compared to 13.1 months for those with incomplete resection<ref name="hithoc_meta" />
* '''HITHOC-enhanced vs surgery-only survival''' — adding heated intrathoracic chemotherapy extended median survival from 11–22.8 months to 13–35 months across seven studies<ref name="hithoc_2025" />
* '''P/D mortality vs EPP mortality''' — P/D achieves 0–3.4% perioperative mortality at experienced centers compared to historically higher rates for EPP, with fewer cardiac and infectious complications<ref name="pd_complications" />
* '''Prolonged air leak vs bronchopleural fistula''' — air leak affects 7.1–23.5% of P/D patients (unique to lung-sparing surgery) while bronchopleural fistula is more common after EPP<ref name="pd_meta_complications" />
* '''Surgical candidates vs non-candidates''' — eligibility requires FEV1 and DLCO at least 50% predicted, ECOG 0–1, and resectable disease at stages I–IIIA, excluding patients with advanced disease or poor lung function<ref name="nct_pd" />
* '''ICU phase vs full recovery''' — patients spend 1–3 days in ICU and 7–14 days in hospital, then require 3–6 months before returning to near-baseline activity<ref name="msk_morbidity" />
* '''P/D lung function vs EPP lung function''' — P/D preserves postoperative pulmonary capacity with continued improvement up to 6 months, while EPP permanently removes the affected lung<ref name="mesonet_recovery" />
 
== Key Facts ==
 
{| class="wikitable" style="width:100%; margin:1em 0; border-collapse:collapse;"
|-
! style="background:#1a5276; color:white; padding:12px; text-align:left;" | Metric
! style="background:#1a5276; color:white; padding:12px; text-align:left;" | Finding
|-
| style="padding:10px; border-bottom:1px solid #dee2e6; font-weight:bold;" | MARS 2 Overall Survival (EPD + chemo vs chemo alone)
| style="padding:10px; border-bottom:1px solid #dee2e6;" | HR not in favor of surgery; 9% 90-day surgical mortality; n = 335 (Lim et al., ''Lancet'' 2024)<ref name="mars2_lancet" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6; font-weight:bold;" | Mount Sinai P/D 30-Day Mortality
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 0% (0/71 patients); 90-day mortality 4.2% (3/71); contemporaneous with MARS 2 enrollment (Gulati & Flores et al., 2026)<ref name="flores_msk" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6; font-weight:bold;" | Lapidot P/D Cohort Survival
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 355 patients; epithelioid patients with MCR achieved superior OS vs large EPP cohorts (Lapidot et al., ''Ann Surg'' 2022)<ref name="lapidot" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6; font-weight:bold;" | MCR vs Incomplete Resection Survival
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Median 28.2 months (MCR) vs 13.1 months (incomplete); p < 0.0001; n = 71 (P/D + HITHOC series, 2019)<ref name="hithoc_meta" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6; font-weight:bold;" | HITHOC Meta-Analysis Effect Size
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Hedges' g = 0.384 ± 0.105; 95% CI: 0.178–0.591; p < 0.001 for median survival; recurrence-free interval Hedges' g = 0.591, p < 0.001 (Oncotarget 2017)<ref name="hithoc_meta" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6; font-weight:bold;" | HITHOC Survival Range (Systematic Review)
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 13–35 months with HITHOC vs 11–22.8 months without; 6 of 7 studies favored HITHOC; 0% HITHOC-related mortality (2025 review)<ref name="hithoc_2025" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6; font-weight:bold;" | HITHOC Renal Insufficiency Risk
| style="padding:10px; border-bottom:1px solid #dee2e6;" | High-dose cisplatin patients 2.7× more likely to develop renal insufficiency; p = 0.006; n = 350 multicenter (Klotz et al. 2021)<ref name="hithoc_renal" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6; font-weight:bold;" | P/D 30-Day Mortality Range (12 Series)
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 0.0–6.8% across published series (2008–2015); high-volume centers 0–3.4% (literature review)<ref name="pd_complications" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6; font-weight:bold;" | Prolonged Air Leak Incidence
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 7.1–23.5% of P/D patients; unique to lung-sparing approach; associated with prolonged hospital stay (meta-analysis 2022)<ref name="pd_meta_complications" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6; font-weight:bold;" | Overall Complication Rate Range
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 9.0–43.0% across 12 published series; wide variance correlates with center volume and experience<ref name="pd_complications" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6; font-weight:bold;" | PPO-DLCO Respiratory Failure Predictor
| style="padding:10px; border-bottom:1px solid #dee2e6;" | PPO-DLCO of 40% identified as best predictor of postoperative respiratory failure; threshold ≥ 50% required (NCT07126509)<ref name="nct_pd" />
|-
| style="padding:10px; font-weight:bold;" | Morbidity Reduction Strategies
| style="padding:10px;" | Early tracheostomy, therapeutic anticoagulation at diagnosis, and gastrostomy placement significantly reduced P/D morbidity (Bou-Samra et al., ''PMC'' 2023)<ref name="msk_morbidity" />
|}
 
== What Is Pleurectomy and Decortication? ==
 
Pleurectomy/decortication (P/D) is one of two primary surgical approaches for [[Mesothelioma Diagnosis and Staging|resectable malignant pleural mesothelioma]]. The procedure involves two distinct steps performed in sequence during a single operation:<ref name="dandell" /><ref name="mlc_pd" />
 
'''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:<ref name="lapidot" /><ref name="mesonet_surgery" />
 
{| class="wikitable" style="width:100%; border-collapse:collapse;"
|-
! style="background:#1a5276; color:white; padding:10px;" | Feature
! style="background:#1a5276; color:white; padding:10px;" | Standard P/D
! style="background:#1a5276; color:white; padding:10px;" | Extended P/D (EPD)
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Pleura Removal'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Parietal and visceral pleura
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Parietal and visceral pleura
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Diaphragm'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Preserved
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Resected and reconstructed
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Pericardium'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Preserved
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Resected and reconstructed
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Lung'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Preserved
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Preserved
|-
| style="padding:10px;" | '''Goal'''
| style="padding:10px;" | Tumor debulking / MCR
| style="padding:10px;" | 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:<ref name="lapidot" /><ref name="mlc_pd" />
 
* 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.<ref name="mars2_lancet" /><ref name="mars2_wclc" />
 
=== Trial Design and Results ===
 
{| class="wikitable" style="width:100%; border-collapse:collapse;"
|-
! style="background:#1a5276; color:white; padding:10px;" | Parameter
! style="background:#1a5276; color:white; padding:10px;" | Detail
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Design'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Phase 3 randomized controlled trial
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Enrollment'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 335 patients (169 surgery + chemotherapy, 166 chemotherapy alone)
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Lead Investigator'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Eric Lim, MB ChB, MD — Royal Brompton Hospital / Imperial College London
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Key Finding'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | EPD was associated with '''worse survival''' to 2 years and more serious adverse events
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''90-Day Surgical Mortality'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''9%''' in the surgery arm
|-
| style="padding:10px;" | '''Investigator Statement'''
| style="padding:10px;" | 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:<ref name="flores_msk" /><ref name="mesoatty_pd" />
 
* '''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.<ref name="flores_msk" /><ref name="dandell_treatment" />
 
== 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.<ref name="hithoc_protocol" /><ref name="mesonet_hithoc" />
 
=== What Is the Standard HITHOC Protocol? ===
 
{| class="wikitable" style="width:100%; border-collapse:collapse;"
|-
! style="background:#1a5276; color:white; padding:10px;" | Parameter
! style="background:#1a5276; color:white; padding:10px;" | Standard Protocol
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Drug'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Cisplatin (80–125 mg/m²), sometimes combined with doxorubicin
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Vehicle'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 2 liters saline
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Temperature'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 40–43°C (104–109°F)
|-
| style="padding:10px;" | '''Duration'''
| style="padding:10px;" | 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:<ref name="hithoc_meta" /><ref name="hithoc_2025" />
 
* '''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.<ref name="hithoc_renal" /><ref name="hithoc_protocol" />
 
== 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.<ref name="nct_pd" /><ref name="mlc_candidacy" />
 
=== What Are the Pulmonary Function Requirements? ===
 
{| class="wikitable" style="width:100%; border-collapse:collapse;"
|-
! style="background:#1a5276; color:white; padding:10px;" | Parameter
! style="background:#1a5276; color:white; padding:10px;" | Threshold
! style="background:#1a5276; color:white; padding:10px;" | Notes
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''FEV1'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | ≥ 50% predicted
| style="padding:10px; border-bottom:1px solid #dee2e6;" | FEV1 < 50% is an exclusion criterion (per NCT07126509)
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''DLCO'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | PPO-DLCO ≥ 50% predicted
| style="padding:10px; border-bottom:1px solid #dee2e6;" | PPO-DLCO of 40% identified as best predictor of postoperative respiratory failure
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''PPO-FEV1 and PPO-DLCO > 60%'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | No further testing needed
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Per ERS/ESTS guidelines — surgery can proceed
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''PPO values 30–60%'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Low-technology exercise testing
| style="padding:10px; border-bottom:1px solid #dee2e6;" | If VO₂max > 20 mL/kg/min (or > 75% predicted), surgery can proceed
|-
| style="padding:10px;" | '''ECOG Status'''
| style="padding:10px;" | 0–1
| style="padding:10px;" | NYHA Functional Class 2B or better for cardiac risk
|}
 
=== What Other Criteria Must Be Met? ===
 
* '''Staging:''' Resectable disease, typically stages I–IIIA per [[Mesothelioma Diagnosis and Staging|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<ref name="nct_pd" /><ref name="dandell_treatment" />
 
== 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:<ref name="pd_complications" /><ref name="pd_meta_complications" />
 
{| class="wikitable" style="width:100%; border-collapse:collapse;"
|-
! style="background:#1a5276; color:white; padding:10px;" | Complication
! style="background:#1a5276; color:white; padding:10px;" | Rate Range
! style="background:#1a5276; color:white; padding:10px;" | Notes
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''30-Day Mortality'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 0.0–6.8%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Most high-volume series report 0–3.4%
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Prolonged Air Leak'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 7.1–23.5%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Most common P/D complication''' — unique to P/D (not seen in EPP)
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Arrhythmia (A-fib/SVT)'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 2.3–21.4%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Most frequently supraventricular tachycardia
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Respiratory Failure'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 2.3–7.1%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Major complication requiring ventilatory support
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Bleeding/Hemorrhage'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 0.0–16.7%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Varies widely by series
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Pneumonia'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 4.5–25%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Aspiration pneumonia is a major concern
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''DVT/VTE'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 4.5–28.6%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Higher rates in some series
|-
| style="padding:10px;" | '''Overall Complication Rate'''
| style="padding:10px;" | 9.0–43.0%
| style="padding:10px;" | Broad range depending on center experience
|}
 
=== How Can Complications Be Reduced? ===
 
A 2023 University of Pennsylvania series identified aspiration pneumonia, DVT, and line sepsis as the primary drivers of P/D morbidity and demonstrated that implementing three targeted strategies significantly reduced these complications:<ref name="msk_morbidity" />
 
* '''Early tracheostomy''' when prolonged intubation is anticipated
* '''Therapeutic anticoagulation''' initiated at diagnosis
* '''Gastrostomy placement''' to prevent aspiration events
 
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.<ref name="pd_meta_complications" /><ref name="pd_empyema" />
 
== 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:<ref name="pd_complications" /><ref name="msk_morbidity" /><ref name="mesonet_recovery" />
 
{| class="wikitable" style="width:100%; border-collapse:collapse;"
|-
! style="background:#1a5276; color:white; padding:10px;" | Phase
! style="background:#1a5276; color:white; padding:10px;" | Timeline
! style="background:#1a5276; color:white; padding:10px;" | Key Milestones
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''ICU Monitoring'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Days 1–3
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Chest tubes in place; epidural or IV pain management; respiratory function, oxygen saturation, and hemodynamic monitoring
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Step-Down Unit'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Days 3–7
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Transfer from ICU if stable; gradual mobilization; chest tube drainage monitored (removal when < 200–300 mL/day with no air leak)
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Pre-Discharge'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Weeks 1–2
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 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'''
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Early Home Recovery'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Weeks 2–6
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Gradual increase in walking; avoid lifting >10 lbs; transition to oral pain medications; follow-up chest X-rays at 2 and 6 weeks
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Rehabilitation Phase'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Weeks 6–12
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Return to light daily activities; pulmonary rehabilitation may begin; adjuvant chemotherapy or radiation may start at 4–8 weeks post-surgery
|-
| style="padding:10px;" | '''Full Recovery'''
| style="padding:10px;" | 3–6 months
| style="padding:10px;" | 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:<ref name="flores_msk" /><ref name="dandell" /><ref name="mlc_centers" />
 
* '''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
 
{| style="width:95%; margin:1em auto; border:1px solid #dee2e6; border-left:4px solid #1a5276; border-radius:4px;"
|-
| style="padding:15px 20px 10px; font-style:italic; font-size:1.05em; line-height:1.5;" | "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."
|-
| style="padding:5px 25px 20px; text-align:right;" | '''— 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:<ref name="pd_history" /><ref name="pd_complications" />
 
* '''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 [[Immunotherapy_for_Mesothelioma|perioperative immunotherapy]] combined with surgery is actively being studied in [[Clinical_Trials|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:<ref name="dandell_treatment" /><ref name="mesoatty_cost" />
 
* '''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 [[Treatment_Options|asbestos trust funds]], VA benefits (for [[Mesothelioma_Types|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
 
== Frequently Asked Questions ==
 
=== What is the difference between pleurectomy/decortication and extrapleural pneumonectomy? ===
 
Pleurectomy/decortication (P/D) is a lung-sparing surgery that removes the diseased pleural lining and all visible tumor while preserving the underlying lung. Extrapleural pneumonectomy (EPP) is a more radical procedure that removes the entire affected lung along with the pleura, diaphragm, and pericardium. P/D achieves 0–3.4% perioperative mortality at high-volume centers compared to historically higher rates for EPP, with lower rates of empyema, atrial fibrillation, and hemorrhage. Most major mesothelioma surgical centers have shifted from EPP to P/D-based approaches over the past two decades.<ref name="lapidot" /><ref name="pd_meta_complications" />
 
=== Does the MARS 2 trial mean patients should avoid P/D surgery? ===
 
The MARS 2 trial reported that extended P/D was associated with worse survival compared to chemotherapy alone, but the results are highly debated within the mesothelioma surgical community. The trial recorded a 9% 90-day surgical mortality rate — more than double the 4.2% rate observed in a contemporaneous Mount Sinai series of 71 patients. Many experts argue that MARS 2 demonstrates the importance of selecting high-volume surgical centers rather than abandoning P/D entirely. Patients should seek evaluation at a center with established mesothelioma surgical expertise before making treatment decisions.<ref name="mars2_lancet" /><ref name="flores_msk" />
 
=== What is HITHOC and how does it improve P/D outcomes? ===
 
HITHOC (Hyperthermic Intrathoracic Chemotherapy) is a procedure in which heated chemotherapy — typically cisplatin at 40–43°C — is perfused directly into the chest cavity immediately after cytoreductive surgery. A meta-analysis found that HITHOC significantly extended median survival compared to surgery alone, and a 2025 systematic review confirmed that six of seven studies demonstrated a survival benefit. Patients who achieved macroscopic complete resection with HITHOC had median survival of 28.2 months versus 13.1 months for incomplete resection.<ref name="hithoc_meta" /><ref name="hithoc_2025" />
 
=== Who qualifies as a candidate for P/D surgery? ===
 
Candidates must meet pulmonary function thresholds including FEV1 of at least 50% predicted and DLCO of at least 50% predicted, along with ECOG performance status of 0–1. Disease must be resectable, typically staged at I–IIIA. Epithelioid histology offers the best surgical outcomes while sarcomatoid subtype is generally not recommended for surgery. The decision requires evaluation by a multidisciplinary team including mesothelioma surgeons, medical oncologists, radiologists, and pathologists.<ref name="nct_pd" /><ref name="mlc_candidacy" />
 
=== What complications are most common after P/D? ===
 
Prolonged air leak is the most common complication unique to P/D, occurring in 7.1–23.5% of patients — this complication does not occur after EPP because the lung is removed entirely. Other complications include cardiac arrhythmia (2.3–21.4%), respiratory failure (2.3–7.1%), pneumonia (4.5–25%), and DVT/VTE (4.5–28.6%). Thirty-day mortality ranges from 0.0–6.8% across published series, with most high-volume centers reporting 0–3.4%. Implementing early tracheostomy, therapeutic anticoagulation, and gastrostomy placement has been shown to significantly reduce P/D morbidity.<ref name="pd_complications" /><ref name="msk_morbidity" />
 
=== How long does recovery take after pleurectomy/decortication? ===
 
Recovery follows a staged progression: 1–3 days of ICU monitoring, transfer to a step-down unit by days 3–7, hospital discharge at 7–14 days, and full recovery to near-baseline activity at 3–6 months. Chest tubes are typically removed by days 7–14, though prolonged air leak may delay discharge. Adjuvant chemotherapy or radiation may begin 4–8 weeks after surgery. Pulmonary function may continue improving for up to 6 months post-surgery, a significant advantage of the lung-sparing approach.<ref name="pd_complications" /><ref name="mesonet_recovery" />
 
=== Why does surgical center volume matter for P/D outcomes? ===
 
Volume-outcome relationships are well established in mesothelioma surgery. High-volume centers consistently report lower mortality, fewer complications, and better long-term survival. The contrast between MARS 2 (9% 90-day mortality across multiple centers) and Mount Sinai (4.2% in a dedicated program) illustrates how surgeon and center experience directly impact patient outcomes. Patients considering P/D should seek evaluation at academic medical centers with dedicated mesothelioma surgical programs such as Memorial Sloan Kettering, Brigham and Women's Hospital, or MD Anderson Cancer Center.<ref name="flores_msk" /><ref name="mlc_centers" />
 
=== Can P/D be combined with immunotherapy? ===
 
The role of perioperative [[Immunotherapy_for_Mesothelioma|immunotherapy]] combined with surgery is actively being studied in [[Clinical_Trials|clinical trials]]. Current multimodal approaches combine P/D with chemotherapy, radiation, and/or HITHOC. Emerging research is evaluating checkpoint inhibitors before or after cytoreductive surgery to determine whether immunotherapy can further improve outcomes for resectable mesothelioma patients. Patients interested in immunotherapy-surgery combinations should inquire about available clinical trials at high-volume mesothelioma centers.<ref name="dandell_treatment" /><ref name="mesonet_surgery" />
 
== Get Help ==
 
Mesothelioma patients and families can connect with experienced legal and medical advocates:
 
* [https://dandell.com/contact-us/ Danziger & De Llano] provides free case evaluations and can connect families with specialized treatment centers — call (866) 222-9990
* [https://www.mesotheliomalawyercenter.org/mesothelioma/ Mesothelioma Lawyer Center] offers resources on treatment options and legal rights
* [https://mesothelioma.net/mesothelioma-treatment/ Mesothelioma.net] provides comprehensive information on surgical options
 
== Quick Statistics ==
 
* Pleurectomy/decortication achieves macroscopic complete resection with 0–3.4% perioperative mortality at experienced centers<ref name="pd_complications" />
* MARS 2 enrolled 335 patients and reported 9% 90-day surgical mortality — more than double the rate at high-volume dedicated programs<ref name="mars2_lancet" />
* Mount Sinai P/D series demonstrated 0% 30-day mortality and 4.2% 90-day mortality in 71 patients operated between 2015 and 2021<ref name="flores_msk" />
* Patients achieving MCR after P/D with HITHOC survived a median 28.2 months compared to 13.1 months for incomplete resection<ref name="hithoc_meta" />
* HITHOC meta-analysis showed statistically significant survival prolongation with Hedges' g of 0.384 and recurrence-free interval improvement with Hedges' g of 0.591<ref name="hithoc_meta" />
* Six of seven studies in a 2025 systematic review demonstrated a survival benefit for HITHOC with zero HITHOC-related deaths reported<ref name="hithoc_2025" />
* Prolonged air leak — the most common P/D-specific complication — affects 7.1–23.5% of patients and may extend hospital stay beyond the typical 7–14 days<ref name="pd_meta_complications" />
* Overall complication rates after P/D range from 9.0% to 43.0% depending on center volume and surgical experience<ref name="pd_complications" />
* P/D surgical candidacy requires FEV1 and DLCO both at least 50% predicted, with PPO-DLCO of 40% identified as the best predictor of postoperative respiratory failure<ref name="nct_pd" />
* Pulmonary function continues improving for up to 6 months after P/D — a recovery advantage not possible after EPP, which permanently removes the lung<ref name="mesonet_recovery" />
 
== Related Resources ==
 
* [[Mesothelioma_Surgery_Overview|Mesothelioma Surgery Overview]]
* [[Mesothelioma_Surgery_Recovery|Mesothelioma Surgery Recovery]]
* [[Heated_Chemotherapy_HITHOC_and_HIPEC|Heated Chemotherapy (HITHOC and HIPEC)]]
* [[Mesothelioma_Biopsy_Procedures|Mesothelioma Biopsy Procedures]]
* [[Immunotherapy_for_Mesothelioma|Immunotherapy for Mesothelioma]]
* [[Mesothelioma_Diagnosis_and_Staging|Mesothelioma Diagnosis and Staging]]
* [[Mesothelioma_Types|Mesothelioma Types]]
* [[Treatment_Options|Treatment Options]]
* [[Clinical_Trials|Clinical Trials]]
 
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== References ==
<references>
<ref name="dandell">[https://dandell.com/ Danziger & De Llano], Mesothelioma Attorneys</ref>
<ref name="dandell_treatment">[https://dandell.com/mesothelioma/treatment/ Mesothelioma Treatment Options], Danziger & De Llano</ref>
<ref name="mlc_pd">[https://mesotheliomalawyercenter.org/treatment/surgery/pleurectomy-decortication/ Pleurectomy and Decortication (P/D) for Mesothelioma], Mesothelioma Lawyer Center</ref>
<ref name="mlc_candidacy">[https://mesotheliomalawyercenter.org/treatment/surgery/ Mesothelioma Surgery: Candidacy and Options], Mesothelioma Lawyer Center</ref>
<ref name="mlc_centers">[https://mesotheliomalawyercenter.org/treatment/cancer-centers/ Mesothelioma Cancer Centers and Specialists], Mesothelioma Lawyer Center</ref>
<ref name="mesonet_surgery">[https://mesothelioma.net/mesothelioma-surgery/ Mesothelioma Surgery Options], Mesothelioma.net</ref>
<ref name="mesonet_hithoc">[https://mesothelioma.net/heated-chemotherapy/ Heated Chemotherapy (HITHOC/HIPEC) for Mesothelioma], Mesothelioma.net</ref>
<ref name="mesonet_recovery">[https://mesothelioma.net/mesothelioma-surgery/recovery/ Recovery After Mesothelioma Surgery], Mesothelioma.net</ref>
<ref name="mesoatty_pd">[https://mesotheliomaattorney.com/mesothelioma/treatment/surgery/ Mesothelioma Surgical Treatment Options], MesotheliomaAttorney.com</ref>
<ref name="mesoatty_cost">[https://mesotheliomaattorney.com/mesothelioma/treatment/ Mesothelioma Treatment and Cost Information], MesotheliomaAttorney.com</ref>
<ref name="mars2_lancet">[https://pubmed.ncbi.nlm.nih.gov/38181795/ Extended Pleurectomy Decortication Versus Chemotherapy for Resectable Pleural Mesothelioma (MARS 2)], Lim E et al., Lancet 2024;403(10421):64-74</ref>
<ref name="mars2_wclc">[https://tlcr.amegroups.org/article/view/73838 Mesothelioma and Radical Surgery 2 (MARS 2) Trial Results], Translational Lung Cancer Research</ref>
<ref name="flores_msk">[https://pubmed.ncbi.nlm.nih.gov/41638523/ Disaster on MARS2? Lessons Learned from Modern Day Outcomes of Surgery for Pleural Mesothelioma (Gulati, Flores et al. 2026)], PubMed / National Library of Medicine</ref>
<ref name="lapidot">[https://mesotheliomalawyercenter.org/treatment/surgery/pleurectomy-decortication/ Pleurectomy/Decortication Outcomes at High-Volume Mesothelioma Centers], Mesothelioma Lawyer Center (citing Lapidot M et al., Ann Surg 2022)</ref>
<ref name="hithoc_protocol">[https://mesothelioma.net/heated-chemotherapy/ Hyperthermic Intrathoracic Chemotherapy (HITHOC) Protocol for Mesothelioma], Mesothelioma.net</ref>
<ref name="hithoc_meta">[https://oncotarget.com/article/19518/ Meta-Analysis of Hyperthermic Intrathoracic Chemotherapy for Malignant Pleural Mesothelioma], Oncotarget (2017)</ref>
<ref name="hithoc_2025">[https://dandell.com/mesothelioma/treatment/ HITHOC and Multimodal Mesothelioma Treatment], Danziger & De Llano</ref>
<ref name="hithoc_renal">[https://pubmed.ncbi.nlm.nih.gov/34572806/ Hyperthermic Intrathoracic Chemotherapy (HITOC) after Cytoreductive Surgery for Pleural Malignancies — A Retrospective, Multicentre Study (Klotz et al. 2021)], PubMed / National Library of Medicine</ref>
<ref name="pd_complications">[https://dandell.com/mesothelioma/treatment/surgery/ Pleurectomy/Decortication Complication Rates and Outcomes], Danziger & De Llano</ref>
<ref name="pd_meta_complications">[https://dandell.com/mesothelioma/surgery/ P/D Versus EPP: Comparative Complication Analysis], Danziger & De Llano</ref>
<ref name="pd_empyema">[https://pubmed.ncbi.nlm.nih.gov/34619137/ Postoperative Empyema After Pleurectomy Decortication for Malignant Pleural Mesothelioma (Lapidot et al. 2022)], PubMed / National Library of Medicine</ref>
<ref name="msk_morbidity">[https://pmc.ncbi.nlm.nih.gov/articles/PMC10518225/ Strategies to Reduce Morbidity Following Pleurectomy and Decortication for Malignant Pleural Mesothelioma (Bou-Samra et al. 2023)], PMC / National Library of Medicine</ref>
<ref name="pd_history">[https://mesotheliomaattorney.com/mesothelioma/treatment/surgery/ History and Evolution of Mesothelioma Surgery], MesotheliomaAttorney.com</ref>
<ref name="nct_pd">[https://clinicaltrials.gov/study/NCT07126509 Partial Pleurectomy for Unresectable Malignant Pleural Mesothelioma], ClinicalTrials.gov</ref>
</references>
 
[[Category:Mesothelioma]]
[[Category:Medical]]
[[Category:Treatment]]
[[Category:Surgery]]
[[Category:Pleurectomy]]
[[Category:Surgical Procedures]]
[[Category:Clinical Trials]]
[[Category:MARS 2]]
[[Category:HITHOC]]
[[Category:Thoracic Surgery]]

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