Mesothelioma Surgery: P/D vs EPP Options

Understanding Mesothelioma Surgery

Surgery for pleural mesothelioma aims to remove as much visible tumor as possible. For patients who are eligible, surgery combined with chemotherapy and other treatments can extend survival and improve quality of life. Two main surgical approaches exist: pleurectomy/decortication (P/D) and extrapleural pneumonectomy (EPP). The right choice depends on the stage of disease, cell type, and overall health.

Pleurectomy/Decortication (P/D)

This procedure removes the lining of the lung (the pleura) along with visible tumors while preserving the lung itself.

What P/D Involves

• Removal of the parietal pleura (outer lining of the chest cavity)
• Removal of the visceral pleura (lining directly around the lung)
• Removal of visible tumor from the diaphragm and pericardium if needed
• The lung remains in place

Advantages of P/D

• Preserves lung function
• Lower surgical mortality rate than EPP
• Shorter hospital stay and recovery
• Average cost: approximately $54,000 (2019 data)

Considerations

P/D may not remove all microscopic disease, which is why it is typically combined with chemotherapy, radiation, or both to target remaining cancer cells.

Extrapleural Pneumonectomy (EPP)

This is the more extensive surgery, removing the entire affected lung along with surrounding tissues.

What EPP Involves

• Removal of the entire lung on the affected side
• Removal of the pleura (both parietal and visceral)
• Removal of the pericardium (lining around the heart)
• Removal of the diaphragm on the affected side
• Reconstruction with synthetic materials

When EPP May Be Considered

• Tumor is confined to one side of the chest
• Patient is in good overall health with strong cardiopulmonary function
• Epithelioid cell type (which responds better to surgery)
• Surgeon has significant experience with the procedure

Considerations

EPP is a major operation performed by only a handful of specialists worldwide. Average cost is approximately $62,400 (2019 data). The procedure has higher surgical risks than P/D, though experienced centers have reduced complication rates significantly.

Comparing P/D and EPP

Factor	P/D	EPP
Lung preserved	Yes	No
Extent of surgery	Less extensive	More extensive
Hospital stay	Shorter	Longer
Recovery time	Faster	Slower
Surgical risk	Lower	Higher
Average cost	~$54,000	~$62,400
Both procedures aim to achieve macroscopic complete resection: removal of all visible tumor. Neither can guarantee removal of microscopic disease, which is why additional treatments are important.

Who Is Eligible for Surgery?

General Eligibility Factors

Cell type: Patients with epithelioid mesothelioma respond better to surgery than those with sarcomatoid or biphasic types. Sarcomatoid tumors tend to grow diffusely, making complete resection difficult. Stage of disease: Surgery is generally an option for patients with stage 1 or stage 2 disease, where tumors remain localized. Advanced disease with spread to distant sites is typically not treated surgically. Overall health: Major surgery requires adequate heart and lung function. Patients must be healthy enough to tolerate the procedure and recover safely. Tumor characteristics: The location and extent of tumor growth affect whether complete resection is feasible.

Evaluation Process

Before surgery, patients undergo extensive testing:

• Pulmonary function tests
• Cardiac evaluation
• CT and PET imaging
• Sometimes mediastinoscopy to assess lymph node involvement

Surgery as Part of Multimodal Treatment

Surgery alone is rarely sufficient. Most treatment plans combine surgery with systemic therapies.

Chemotherapy

The standard chemotherapy regimen uses pemetrexed combined with cisplatin or carboplatin. Chemotherapy may be given:

• Before surgery (neoadjuvant): To shrink tumors before resection
• After surgery (adjuvant): To target remaining microscopic disease

Radiation Therapy

Radiation may follow surgery to treat areas where tumor recurrence is likely. It can target the surgical bed and areas where microscopic disease may remain.

Immunotherapy

Immune checkpoint inhibitors like nivolumab and ipilimumab are increasingly being studied in combination with surgery, particularly for patients with sarcomatoid or biphasic cell types.

Peritoneal Mesothelioma Surgery

For mesothelioma that develops in the abdominal lining, surgical approaches differ.

Cytoreductive Surgery with HIPEC

This procedure combines:

• Cytoreductive surgery: Removal of visible tumors from the abdominal cavity
• HIPEC (heated intraperitoneal chemotherapy): Heated chemotherapy solution circulated through the abdomen during surgery

PIPAC

For patients who cannot undergo major surgery, pressurized intraperitoneal aerosol chemotherapy (PIPAC) offers a minimally invasive alternative:

• Can be repeated every 6–8 weeks
• Recovery measured in days rather than weeks
• One case report documented a patient receiving 24 PIPAC treatments over seven years with sustained tumor control

Recovery and Follow-Up

After P/D

• Hospital stay: typically 5–7 days
• Return to normal activities: 4–8 weeks
• Follow-up imaging every 3–4 months initially

After EPP

• Hospital stay: typically 7–14 days
• Return to normal activities: 8–12 weeks or longer
• Adjustment to breathing with one lung
• Follow-up imaging every 3–4 months initially

Finding a Mesothelioma Surgeon

Mesothelioma surgery requires specialized expertise. Look for:

• Surgeons at designated cancer centers or academic medical centers
• Surgeons who perform a high volume of mesothelioma operations
• Multidisciplinary teams that include thoracic surgeons, oncologists, and radiation oncologists Several major cancer centers in the United States have mesothelioma surgery programs, including Brigham and Women’s Hospital, MD Anderson Cancer Center, Memorial Sloan Kettering, and the University of Chicago.