Pleurectomy/Decortication vs Extrapleural Pneumonectomy: How Mesothelioma Surgery Decisions Are Made

The choice between pleurectomy/decortication and extrapleural pneumonectomy is one of the highest-stakes decisions in pleural mesothelioma care. The two operations are not interchangeable. They were not designed to do the same thing, and the trial evidence around them has shifted substantially in the past 15 years. Patients who consult two different programs often hear two different recommendations.

This guide is for people who have been told they are surgical candidates and are now weighing what surgery actually means. It draws on the published primary literature: the MARS and MARS2 randomised trials, the Cao 2014 meta-analysis, the Flores 2008 multicenter analysis, the Sugarbaker BWH series, and the IASLC Mesothelioma Staging Project. It does not include marketing language, and it does not rank surgeons or centers. The point is to clarify what each operation is, what each trial showed, and what the decision actually involves.

What Each Operation Is

Both procedures aim at what surgeons call macroscopic complete resection (MCR), which is removal of all visible tumor. They get there by very different routes.

Pleurectomy/decortication (P/D) is a lung-sparing operation. The surgeon enters the chest, peels the parietal pleura away from the chest wall, and decorticates (strips) the visceral pleura off the surface of the lung. The diaphragm and pericardium may be partially resected and reconstructed if tumor has invaded them, but the underlying lung is preserved. Patients leave the operating room with both lungs still in place.

Extrapleural pneumonectomy (EPP) is a more radical operation. The surgeon removes the entire lung on the affected side along with the pleura, the diaphragm on that side, and the pericardium. The diaphragm and pericardium are reconstructed with synthetic patches. Patients leave the operating room living on a single contralateral lung.

The National Cancer Institute’s Mesothelioma Treatment PDQ describes both procedures and notes that surgical management is most often offered as part of multimodality therapy that combines surgery with chemotherapy and, in some protocols, radiation. The Sugarbaker group at Brigham and Women’s Hospital published the foundational EPP trimodality series in the Journal of Thoracic and Cardiovascular Surgery in 1999. That paper, which described 183 patients, established EPP as a recognized surgical option and identified resection margins, nodal status, and cell type as the strongest predictors of long-term survival.

The MARS Trial and What It Changed

The Mesothelioma and Radical Surgery (MARS) trial, published by Treasure and colleagues in Lancet Oncology in 2011, was the first randomised study to test whether EPP within trimodality therapy improved outcomes over chemotherapy alone. It was a feasibility trial, not powered to prove an efficacy difference, and it enrolled 50 patients across 12 UK hospitals.

The results were stark. Patients randomised to EPP had high perioperative mortality, the median survival in the EPP arm was numerically shorter than in the no-EPP arm, and quality-of-life scores after surgery were worse. Treasure and colleagues concluded directly: “These results, although from a feasibility study with few patients, suggest that radical surgery in the form of EPP, within this multimodality strategy, is not practicable and does not offer a realistic survival benefit.”

MARS was small, and its design and conclusions drew immediate disagreement from EPP proponents at high-volume programs in the United States, who pointed to retrospective series with substantially better outcomes. But the trial reframed the surgical conversation. Most major centers in Europe began moving away from EPP, and the field’s center of gravity shifted toward lung-sparing P/D.

MARS2 and the Question Being Asked Today

MARS2 (NCT02040272, funded by the UK NIHR Health Technology Assessment Programme) was designed to answer the next question: with EPP largely set aside, does extended pleurectomy/decortication itself add survival to chemotherapy alone in resectable disease?

The trial enrolled 335 patients across 26 UK hospitals between 2015 and 2020 and randomised them to chemotherapy with active symptom control or to chemotherapy plus extended P/D. The results, published by Lim and colleagues in the New England Journal of Medicine in 2024, did not show an overall survival benefit from adding surgery. Median overall survival in the chemotherapy-only arm was at least as long as in the surgery arm, with a hazard ratio favoring chemotherapy alone (HR 1.19; 95% CI 0.94 to 1.50). Ninety-day mortality and serious adverse events were higher in the surgery arm.

The trial’s investigators framed the implication carefully: MARS2 was the largest randomised mesothelioma surgical trial ever completed, and it does not support routine extended P/D for resectable disease outside of investigational protocols.

That conclusion is not the end of the surgical conversation. MARS2 tested a specific operation in a specific multimodality protocol against active symptom control plus chemotherapy. It did not address every clinical situation, and it did not enroll patients identical to those treated at high-volume specialty centers in the United States. But it raised the bar substantially for what data are needed to recommend surgery, and it shifted clinical guidance toward chemotherapy and immunotherapy as the standard of care, with surgery best considered in the context of clinical trials or carefully selected patients at experienced centers.

What the Comparative Literature Shows

When P/D and EPP are compared head-to-head in observational studies, the picture is consistent across multiple datasets.

In the largest pre-MARS2 comparison, Flores and colleagues analyzed 663 consecutive patients treated at three high-volume programs (Memorial Sloan Kettering, the Brigham, and the Dana-Farber) and reported their findings in the Journal of Thoracic and Cardiovascular Surgery in 2008. After adjusting for stage, histology, sex, and multimodality therapy, EPP carried a hazard ratio of 1.4 for death compared with P/D, meaning P/D was associated with longer adjusted survival than EPP. The investigators were cautious about over-interpreting the result, since the choice between procedures in this dataset was not randomised, but the direction of the finding aligned with what subsequent studies would show.

Cao and colleagues’ 2014 systematic review and meta-analysis in Lung Cancer pooled outcomes across published P/D and EPP series. The headline findings: perioperative mortality was lower for P/D than for EPP (approximately 2.1% vs 6.8%), perioperative morbidity was lower for P/D (approximately 35.6% vs 56.9%), and there was no statistically significant difference in long-term overall survival between the two procedures. Put plainly, P/D carried less upfront risk and produced equivalent long-term survival in the pooled data.

The Brigham and Mount Sinai high-volume series tell the same story from different angles. The Sugarbaker EPP era at the Brigham produced strong outcomes in highly selected patients with epithelioid histology and negative nodes, but those outcomes did not generalize beyond the high-volume center. Mount Sinai under Dr. Raja Flores became one of the leading lung-sparing P/D programs and reported outcomes comparable to or better than the EPP literature with substantially lower perioperative risk.

The Center-Volume Effect

For both procedures, where the operation is performed matters as much as which operation is chosen. The center-volume effect in pleural mesothelioma surgery is well documented in the published series. Perioperative mortality, complication rates, and long-term outcomes are consistently better at high-volume programs that operate on these patients regularly than at community centers that see only a handful per year.

The reasons are not mysterious: patient selection, anesthesia experience, intraoperative decision-making, postoperative critical care, and the integration of surgery with chemotherapy and radiation are all easier when the team performs the operation often. The Sugarbaker group at the Brigham, the Flores group at Mount Sinai, the Bueno group, Memorial Sloan Kettering, MD Anderson, and a small number of other US programs have decades of mesothelioma surgical experience. The published outcomes from those programs do not translate to operations performed by surgeons who do one or two cases per year.

This is not a marketing point. It is a finding that appears repeatedly in the surgical literature, and it has direct implications for the second-opinion conversation. If your home institution is not a high-volume mesothelioma program, traveling to one for the surgical opinion is one of the more consequential things a patient can do.

Who Is Eligible for Surgery at All

Most patients diagnosed with pleural mesothelioma are not surgical candidates. The CDC reports approximately 3,000 new diagnoses each year in the United States, and the majority present with disease that is too advanced for any curative-intent operation, or with a histology that does not respond well to surgery, or with comorbidities that make a major thoracic operation unsafe.

The IASLC Mesothelioma Staging Project, led by Rusch and colleagues, summarized the criteria most programs use:

• Histology. Surgery is generally limited to patients with epithelioid mesothelioma, or biphasic mesothelioma in which the epithelioid component predominates. Sarcomatoid histology is associated with much worse outcomes after surgery, and most programs do not offer curative-intent operations to those patients.
• Performance status. Patients are generally expected to have an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1, meaning they are fully active or only mildly limited.
• Stage. Curative-intent surgery is most often offered for early-stage disease (clinical stage I-II, sometimes IIIA in selected cases). Bulky nodal disease, contralateral pleural involvement, distant metastases, and chest wall invasion beyond a single resectable focus generally exclude surgery.
• Pulmonary reserve. EPP candidates need adequate function in the contralateral lung to live on it; P/D candidates need adequate cardiopulmonary reserve to tolerate a major thoracic operation.
• MCR feasibility. The operative goal is macroscopic complete resection. If the surgeon cannot reasonably expect to remove all visible tumor, the case is generally not offered curative-intent surgery.

These criteria are not arbitrary. They were derived from the IASLC database and have been refined across multiple TNM revisions, including the 8th edition of the AJCC staging system published in 2017. Programs may interpret the edges of these criteria differently, which is one reason patients sometimes hear different recommendations from different centers.

Recovery and Long-Term Lung Function

The post-operative course differs substantially between the two operations.

After P/D, the lung is preserved. Air leaks from the decorticated lung surface are common in the first days after surgery and may prolong chest-tube drainage, but pulmonary function over the long term is largely retained. Most patients who recover well from P/D return to a level of activity close to their pre-operative baseline.

After EPP, the operated lung is gone. Patients live on a single lung permanently. Exercise tolerance is reduced, dyspnea on exertion is common and chronic, and cardiopulmonary complications including atrial fibrillation, pulmonary embolism, and right heart strain are more frequent than after P/D. The operative reconstruction of the diaphragm and pericardium also creates long-term considerations that P/D does not. Most modern programs reserve EPP for very narrowly selected patients, and the procedure is performed substantially less often than it was 15 years ago.

The long-term quality-of-life difference between the two operations is part of why MARS2 and the lung-sparing literature have shifted the field. Even when survival outcomes are equivalent, the lived experience of recovery from P/D is generally better than from EPP.

What This Means for the Decision

Three points come out of the primary literature consistently.

First, the modern data do not support EPP as a default operation for most patients. MARS raised serious questions about EPP within trimodality therapy, and most major programs have moved away from it. Where EPP is still offered, it is typically in narrowly selected patients at high-volume centers within carefully structured multimodality protocols.

Second, even P/D is no longer a default recommendation. MARS2 did not show a survival benefit from adding extended P/D to chemotherapy. The trial’s investigators do not argue that surgery has no role; they argue that the benefit, if there is one, is not clearly established by the largest randomised data we have, and that surgery should be considered in the context of trials and selected patients at experienced centers rather than as routine care for resectable disease.

Third, where a patient is operated on matters. Outcomes in the published series are not uniform. The Sugarbaker, Flores, Bueno, and Rusch programs published their data because they have the volume, the multidisciplinary infrastructure, and the patient selection to produce better outcomes than community centers. A second opinion from one of those centers is not a luxury for the patient who is being told they need surgery. It is part of due diligence on a high-stakes decision.

Where MesoWatch can be useful is on the architecture of that decision: what each operation is, what the trials actually showed, and what questions to bring to the surgical conversation. The clinical decision belongs to the patient and their thoracic surgical and medical oncology team. The decision is easier to make well when the published evidence is in front of the patient rather than mediated through marketing copy.

For the parallel question of which systemic therapy to pair with surgery (or to substitute for it), see our companion guide on first-line treatment decisions in 2026.

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