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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Executive Summary

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. Whether MCR is achievable is the question that governs the decision to operate at all: where it cannot be achieved, surgery is palliative rather than survival-directed. 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 MARS 2 trial (Lim et al., Lancet Respiratory Medicine, 2024) introduced significant controversy by reporting that extended P/D plus chemotherapy was associated with worse survival — a median 19.3 months versus 24.8 months for chemotherapy alone, a difference in restricted mean survival time at 2 years of -1.9 months (95% CI -3.4 to -0.3; p=0.019) — 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. The trial's interpretation remains formally contested within the surgical community.

At-a-Glance

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
• MARS 2 surgery vs chemotherapy alone — 335-patient RCT found extended P/D plus chemotherapy produced worse survival (median 19.3 vs 24.8 months; difference in restricted mean survival time at 2 years -1.9 months, 95% CI -3.4 to -0.3, p=0.019) and 9% 90-day surgical mortality compared to chemotherapy alone; the trial's interpretation is formally contested
• 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%
• Complete vs incomplete resection — in a 71-patient P/D series, patients achieving macroscopic complete resection survived a median 28.2 months compared to 13.1 months for those with incomplete resection (p < 0.0001)
• HITHOC-enhanced vs surgery-only survival — in selected patients with limited, epithelioid disease, adding heated intrathoracic chemotherapy extended median survival from 11–22.8 months to 13–35 months across seven studies
• 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
• 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
• 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
• 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
• 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

Key Facts

Metric	Finding
MARS 2 Overall Survival (EPD + chemo vs chemo alone)	Restricted mean survival time favoured chemotherapy alone; 9% 90-day surgical mortality reported in the surgery arm; n = 335 (Lim et al., Lancet 2024). Interpretation formally contested in a 2025 multi-author perspective
Mount Sinai P/D 30-Day Mortality	0% (0/71 patients); 90-day mortality 4.2% (3/71); contemporaneous with MARS 2 enrollment (Gulati & Flores et al., 2026)
Lapidot P/D Cohort Survival	355 patients; epithelioid patients with MCR achieved superior OS vs large EPP cohorts (Lapidot et al., Ann Surg 2022)
MCR vs Incomplete Resection Survival	Median 28.2 months (MCR) vs 13.1 months (incomplete); p < 0.0001; n = 71 (Klotz et al., J Thorac Dis 2019)
HITHOC Meta-Analysis Effect Size	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)
HITHOC Survival Range (Systematic Review)	13–35 months with HITHOC vs 11–22.8 months without; 6 of 7 studies favored HITHOC; 0% HITHOC-related mortality (2025 review). Benefit is reported in selected patients with limited, epithelioid disease
HITHOC Renal Insufficiency Risk	High-dose cisplatin patients 2.7× more likely to develop renal insufficiency; p = 0.006; n = 350 multicenter (Ried et al. 2021)
P/D 30-Day Mortality Range (12 Series)	0.0–6.8% across published series (2008–2015); high-volume centers 0–3.4% (literature review)
Prolonged Air Leak Incidence	7.1–23.5% of P/D patients; unique to lung-sparing approach; associated with prolonged hospital stay (meta-analysis 2022)
Overall Complication Rate Range	9.0–43.0% across 12 published series; wide variance correlates with center volume and experience
PPO-DLCO Respiratory Failure Predictor	PPO-DLCO of 40% identified as best predictor of postoperative respiratory failure; threshold ≥ 50% required (NCT07126509)
Morbidity Reduction Strategies	Early tracheostomy, therapeutic anticoagulation at diagnosis, and gastrostomy placement significantly reduced P/D morbidity (Bou-Samra et al., PMC 2023)

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. This comparison is secondary to the question addressed below — whether macroscopic complete resection is achievable at all. Where it is, the choice between P/D and EPP is a question of which operation can deliver it at the lower cost to the patient. 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

Is Macroscopic Complete Resection Achievable?

Before one operation is compared to another, the decision to operate turns on a prior question: whether macroscopic complete resection (MCR) — removal of all visible tumor — can realistically be achieved in a given patient. David Sugarbaker set out this framing in 2006, arguing that MCR is the defining goal of primary surgery within multimodal therapy for pleural mesothelioma and the standard against which any operation should be judged.

In practice this makes surgical decision-making a sequence of two questions rather than one:

• First: is MCR achievable in this patient, given tumor distribution, histology, stage, and fitness?
• Second: if it is, can P/D or extended P/D achieve it — or is EPP required?

Where MCR is not achievable, an operation is not a smaller version of the same treatment. It becomes palliative surgery, undertaken to relieve symptoms such as trapped lung or recurrent pleural effusion rather than to extend survival. Both are legitimate, but they are different treatments with different goals, and patients are best served by knowing which one is being offered.

What Does the Evidence Show About MCR?

The survival difference attached to this distinction is among the largest reported anywhere in mesothelioma surgery. In a 71-patient P/D series, patients who achieved macroscopic complete resection had a median survival of 28.2 months against 13.1 months for those left with incomplete resection (p < 0.0001). Lapidot et al. found the same pattern across 355 P/D patients, where epithelioid patients achieving MCR had superior overall survival to large EPP cohorts.

The pole star should be a single question: is macroscopic complete resection achievable? If it is, the next question is whether P/D or EPP can achieve it. If it is not, the operation is palliative.

— Luciano Mutti, MD, PhD, Professor of Oncology, UniCamillus, Rome

This is also the lens through which the surgical trial evidence is most usefully read. A trial that enrolls patients in whom MCR was not achievable is not testing the same intervention as a series reporting outcomes in patients where it was — a distinction at the centre of the debate over MARS 2 described below.

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
Median Overall Survival	19.3 months (surgery + chemotherapy) vs 24.8 months (chemotherapy alone); difference in restricted mean survival time at 2 years -1.9 months (95% CI -3.4 to -0.3), p=0.019
90-Day Surgical Mortality	9% in the surgery arm (14 of 157 who underwent surgery)

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, on patients in whom macroscopic complete resection is achievable.

The disagreement was formalised in 2025, when nine leading thoracic surgeons and researchers — including Eric Lim, MARS 2's own principal investigator, writing alongside his critics — published a structured perspective in the Journal of Thoracic Oncology setting out both the arguments supporting the trial's interpretation and the objections to its conduct. The points at issue included patient selection and histologic subtype, the timing of randomisation, the use of preoperative staging, quality assurance, statistical method, and the reasons behind the surgical mortality observed. The authors concluded that the future role of surgery will be shaped by consensus guidelines and payer willingness, and that how MARS 2 is interpreted may itself determine that role.

If MARS 2 is taken at face value, no mesothelioma patient would ever go under the knife. But where macroscopic complete resection is achievable — by P/D or by EPP — surgery remains a reasonable indication. In my own practice, most of my long-survival patients had a complete macroscopic resection.

— Luciano Mutti, MD, PhD, Professor of Oncology, UniCamillus, Rome

How Does the Broader Evidence Compare to MARS 2?

Several analyses published after MARS 2 help place its findings in context — some reinforcing its caution about surgery in unselected patients, others affirming P/D's advantage over the more radical EPP when surgery is pursued, and one setting MARS 2 against a second surgical trial with markedly different results.

A 2025 systematic review and meta-analysis of 24 comparative studies and 3,943 patients (Brivio et al., Journal of Clinical Medicine, 2025) found that P/D was associated with a significantly longer mean overall survival than EPP — a difference of 7.01 months (95% CI 1.15–12.86; p=0.018) — and a 2.79-fold lower 30-day mortality (odds ratio 2.79 for EPP; 95% CI 1.29–6.05; p=0.009). Notably, P/D patients were on average 3.78 years older than EPP patients, indicating that the lung-sparing approach delivered superior outcomes even in a less-fit population.

A National Cancer Database analysis of 21,768 mesothelioma patients (Zhan et al., Annals of Thoracic Surgery, 2026) reinforced MARS 2's central message: among propensity-matched patients, those treated with chemotherapy and no surgery achieved a 5-year overall survival of 16.4% — statistically identical to the 16.4% seen in patients treated with chemotherapy plus surgery (median 22.9 vs 21.9 months; p=0.77). Young age, treatment at an academic center, chemotherapy, epithelioid histology, and stage I disease predicted prolonged survival without surgery — confirming that, for carefully selected patients, long-term survival is achievable without an operation.

A 2025 review in the European Journal of Surgical Oncology (Lang-Lazdunski) set MARS 2 alongside EORTC-L1205, a separate trial of extended P/D in which surgical mortality was 1.7% — against the 9% recorded in MARS 2. The review noted that recent series of well-selected surgical patients report median survivals of 34–38 months, where the best available systemic regimens — combining chemotherapy agents, anti-angiogenics, or immune checkpoint inhibitors — offer 18–24 months. Its conclusions were that careful patient selection is essential to avoid futile or detrimental surgery, and that preservation of the diaphragm is associated with lower morbidity and mortality and better long-term outcomes.

Taken together, these analyses narrow the question without settling it. The trials differ in patient selection, in surgical technique, and in perioperative mortality by a factor of five, and no randomised comparison has yet isolated the effect of surgery in patients where macroscopic complete resection was actually achieved. A definitive take-home message is not currently available from the published evidence.

The honest bottom line is that no firm conclusion can be drawn. We are getting closer, but without a solidly conducted randomised trial there is no take-home message that can be set in stone.

— Luciano Mutti, MD, PhD, Professor of Oncology, UniCamillus, Rome

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. Across this literature the benefit is reported in selected patients with localized, early-stage, epithelioid disease in whom macroscopic complete resection was achieved; it has not been demonstrated in advanced or unselected disease. The published sources describe the population as localized and early-stage without naming a stage; reviewing for this page, Professor Luciano Mutti places the practical bound at Stage II — "not more extended than that."

• 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 (Klotz et al.); 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 (Elsayed et al.); HITHOC group (cisplatin 125 mg/m², 70 min, 40–43°C) vs. surgery only; 30-day mortality 0% (HITHOC) versus 3.3% (surgery only). The authors concluded HITHOC after P/D is a safe option that may improve survival specifically for selected patients with localized epithelial mesothelioma, and that earlier-stage patients are the more likely to benefit

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.

How Is Perioperative Immunotherapy Being Combined With P/D?

The most active frontier in mesothelioma surgery research is the use of immune checkpoint inhibitors before (neoadjuvant) and after (adjuvant) cytoreductive surgery. A phase 2 trial from Johns Hopkins (Reuss et al., Nature Medicine, 2025) tested neoadjuvant nivolumab alone versus nivolumab plus ipilimumab in patients with resectable epithelioid or biphasic pleural mesothelioma, followed by surgery and one year of nivolumab.

• In the nivolumab-plus-ipilimumab arm, median overall survival reached 28.6 months and median progression-free survival 19.8 months, compared with a 9.6-month progression-free survival in the nivolumab-monotherapy arm.
• Surgery proceeded in 81–86% of patients across both arms, and treatment was well tolerated, with a single dose-limiting toxicity in each arm — establishing that perioperative checkpoint blockade is feasible in this setting.
• The trial also identified circulating tumor DNA (ctDNA) as a novel biomarker: patients with detectable ctDNA before surgery had significantly shorter progression-free survival, raising the possibility that liquid biopsy could one day help select which patients proceed to surgery.

These findings are early and should be read as such. They come from a single 30-patient phase 2 trial and describe feasibility and preliminary signal, not established benefit: no randomised trial has compared perioperative immunotherapy against the current standard of care in this setting, and results of this kind have not consistently held up when tested at scale. The 2025 ASCO guideline reflects the same caution, stating that neoadjuvant immunotherapy-based treatment may be offered to surgical candidates while noting there is insufficient evidence to recommend adjuvant immunotherapy after surgery.

Sequencing remains unsettled. The question of whether systemic treatment is better delivered before surgery (induction) or after it (adjuvant) has been debated in mesothelioma for as long as multimodal therapy has been offered, and analyses of chemotherapy timing after P/D or EPP have not resolved it. For a fit patient with early disease, the better-supported sequence remains surgery directed at macroscopic complete resection followed by adjuvant chemotherapy. The cautions that apply to induction chemotherapy apply with greater force to induction immunotherapy, where the evidence base is substantially thinner. Patients considering this route should do so through a clinical trial at a high-volume center.

For a fit patient with early disease, the best option is surgery aimed at complete macroscopic resection followed by adjuvant chemotherapy. The cautions that apply to induction chemotherapy apply with even greater force to induction immunotherapy.

— Luciano Mutti, MD, PhD, Professor of Oncology, UniCamillus, Rome

Who Is a Candidate for P/D Surgery?

Surgery is an option for a small subgroup — the patients in whom macroscopic complete resection is genuinely achievable. If preoperative staging suggests that complete macroscopic resection is achievable then and there, the best option is the operating room without delay: the medical treatments are not good enough, and the risk of progressive disease with loss of the surgical window is too high for these patients.

— Luciano Mutti, MD, PhD, Professor of Oncology, UniCamillus, Rome

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.

Why Does Staging Need to Be Thorough Before Surgery?

Because the decision to operate turns on whether macroscopic complete resection is achievable, the accuracy of preoperative staging governs everything downstream. Imaging alone can understate nodal involvement, and guidelines accordingly direct clinicians toward invasive confirmation rather than relying on scans. The 2025 ASCO guideline recommends that mediastinoscopy and/or endobronchial ultrasound (EBUS) should be considered for patients being evaluated for maximal surgical cytoreduction when mediastinal nodes are enlarged and/or PET-avid. Reviewing this page, Professor Luciano Mutti made the same point more directly — that clinicians should not shy away from invasive staging in this setting, because the information gained outweighs the burden of obtaining it. No published guideline specifies a node-size threshold at which invasive staging becomes mandatory.

What Do Current Guidelines Recommend?

The two most recent expert guidelines both position P/D ahead of EPP for patients who are surgical candidates:

• The 2025 ASCO Guideline Update (Kindler et al., Journal of Clinical Oncology, 2025) issued a strong recommendation that surgery should not be offered to all anatomically resectable patients. When maximal cytoreduction is warranted, lung-sparing P/D is the first choice; EPP is reserved for highly selected patients at centers of excellence with hemithoracic radiation capability. The guideline recommends against maximal cytoreduction for sarcomatoid disease and now advises that all mesothelioma patients be offered germline (BAP1) testing.
• The 2026 Society of Thoracic Surgeons Expert Consensus (Velotta et al., Annals of Thoracic Surgery, 2026), developed through a modified Delphi process across an international multidisciplinary panel, concluded that pleurectomy/decortication or extended P/D is strongly favored over extrapleural pneumonectomy as the approach to resection, and that surgery — when appropriate — should be part of a multimodal plan directed by a tumor board including thoracic surgeons with mesothelioma expertise.

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 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:

• 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.

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
• 2023–2024: The MARS 2 trial was presented at the 2023 World Conference on Lung Cancer and formally published in Lancet Respiratory Medicine in 2024, reporting 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

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.

Does the MARS 2 trial mean patients should avoid P/D surgery?

No — but it does change how the decision should be made. MARS 2 reported that extended P/D was associated with worse survival compared to chemotherapy alone, and its interpretation is formally contested within the mesothelioma surgical community; a 2025 multi-author perspective in the Journal of Thoracic Oncology, co-written by the trial's own principal investigator alongside his critics, set out the objections in detail. The trial recorded a 9% 90-day surgical mortality rate — more than double the 4.2% seen in a contemporaneous Mount Sinai series, and more than five times the 1.7% reported in the EORTC-L1205 surgical trial. The governing question is not whether P/D works in general, but whether macroscopic complete resection is achievable in a specific patient: where it is, surgery remains a reasonable option; where it is not, an operation is palliative rather than survival-directed. Because no randomised trial has yet isolated surgery's effect in patients where complete resection was actually achieved, no firm conclusion can be drawn either way. Patients should seek evaluation at a center with established mesothelioma surgical expertise before making treatment decisions.

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 found 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. This benefit has been reported in selected patients with localized, early-stage, epithelioid disease in whom complete resection was achieved; it has not been demonstrated in advanced or unselected disease, and earlier-stage patients appear the more likely to benefit.

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.

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.

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.

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.

Can P/D be combined with immunotherapy?

The role of perioperative immunotherapy combined with surgery is actively being studied in clinical trials. Current multimodal approaches combine P/D with chemotherapy, radiation, and/or HITHOC. A 2025 phase 2 trial from Johns Hopkins (Reuss et al., Nature Medicine) found that neoadjuvant nivolumab plus ipilimumab before surgery achieved a median overall survival of 28.6 months and progression-free survival of 19.8 months, with circulating tumor DNA emerging as a potential biomarker of surgical eligibility. This was a single 30-patient trial with no randomised comparison against standard care, so it establishes feasibility rather than benefit, and it does not make perioperative immunotherapy a standard option. For a fit patient with early disease, the better-supported sequence remains surgery aimed at complete resection followed by adjuvant chemotherapy. Patients interested in immunotherapy-surgery combinations should inquire about available clinical trials at high-volume mesothelioma centers.

External Links

• Danziger & De Llano — mesothelioma legal resources
• Mesothelioma Lawyer Center — treatment and legal resources
• Mesothelioma.net — surgical treatment information

Quick Statistics

• Pleurectomy/decortication achieves macroscopic complete resection with 0–3.4% perioperative mortality at experienced centers
• MARS 2 enrolled 335 patients and reported 9% 90-day surgical mortality — more than double the rate at high-volume dedicated programs
• Mount Sinai P/D series demonstrated 0% 30-day mortality and 4.2% 90-day mortality in 71 patients operated between 2015 and 2021
• Patients achieving MCR after P/D with HITHOC survived a median 28.2 months compared to 13.1 months for incomplete resection (Klotz et al., n = 71)
• 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
• Six of seven studies in a 2025 systematic review demonstrated a survival benefit for HITHOC with zero HITHOC-related deaths reported
• 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
• Overall complication rates after P/D range from 9.0% to 43.0% depending on center volume and surgical experience
• 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
• Pulmonary function continues improving for up to 6 months after P/D — a recovery advantage not possible after EPP, which permanently removes the lung

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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Medically reviewed by Dr. Luciano Mutti, MD, PhD — Professor of Oncology, UniCamillus, Rome · Medical Oncology
Last reviewed: 2026-08-28 · Medical review covers clinical accuracy only and is not an endorsement of any legal service. See Editorial Standards for our editorial process.