Mesothelioma Pleurectomy with decortication, or P/D, is a surgical procedure used to treat pleural mesothelioma. Pleurectomy removes the lining around the lung (the pleura) (the pleura). Tumors or scar tissue on the surface of the lung are removed during decortication. P/D is a surgery that saves the lung, so it is called a lung-sparing surgery.
What Is mesothelioma Pleurectomy with Decortication (P/D)?
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| mesothelioma pleurectomy with decortication Surgery (P/D) |
Mesothelioma Pleurectomy with decortication (P/D) is a two-stage surgical procedure. The membrane covering the lung is removed during the pleurectomy stage (the pleura). During the decortication stage, abnormal tissues that have grown on or around the lung are removed. These abnormal tissues may include cancer or scar tissue.
Doctors use P/D to treat a number of conditions, including pleural mesothelioma.
Malignant mesothelioma is a cancer that starts in the linings of certain tissues and is caused by asbestos. It happens in four main places. Pleural mesothelioma is the most common type of mesothelioma. Malignant pleural mesothelioma (MPM) grows in the lining outside the lungs (the pleura).
How Does Pleurectomy with Decortication Treat Mesothelioma?
Pleural mesothelioma is treated with P/D by removing the cancerous tissue. The outside layer of the lung is surgically removed during a P/D procedure (the pleura). Doctors will also remove visible tumours from the chest cavity. There are several variations of this procedure, but they all share a common goal.
The goal of many surgical treatments for mesothelioma, including P/D, is macroscopic complete resection (MCR) (MCR). In MCR, all of the tumour tissue that can be seen with the naked eye is removed. Removal of tumour tissue is also known as cytoreduction or cytoreductive surgery (CRS).
In general, a patient's chances of living for a long time are better if doctors can remove as much cancer tissue as possible.
In order to get rid of as many cancer cells as possible, P/D is often used as part of a multimodal treatment strategy. It's hard to get rid of all cancer cells. In an effort to eradicate all cancer cells and increase survival, multimodal treatment combines various therapies. Some multimodal treatment plans combine P/D with chemotherapy and/or radiation therapy.
Types of Pleurectomy Decortication for mesothelioma (P/D)
The American Society of Clinical Oncology (ASCO) says that there are different ways to define P/D. As a result, ASCO has outlined the two main types of P/D as follows.
Pleurectomy/Decortication (P/D) is the surgical removal of both layers of the pleura (the parietal and visceral pleura)
Extended Pleurectomy/Decortication (ePD): Surgical removal of both layers of the pleura as well as cancerous areas of the diaphragm and heart lining (pericardium)
Traditional P/D and ePD are thought to be lung-sparing treatments for mesothelioma. This name comes from the fact that neither P/D nor ePD remove the lung. Extrapleural pneumonectomy (EPP) is another pleural mesothelioma surgery that removes the affected lung.
ASCO says that P/D has less risk during surgery and in the long run than EPP. Thus, ASCO recommends P/D as the first choice in surgical treatment of pleural mesothelioma.
What Does Non-Incisional Pleurectomy/Decortication Mean for Patients?
Recently, surgeons have created "non-incisional" P/D. The name of the procedure makes it sound like there won't be any cuts, but this is not true. Instead, the term "non-incisional" refers to the way that surgeons remove the pleura without making any cuts.
In a typical P/D, doctors cut into the inner layer of the pleura (the visceral pleura). This lets them remove parts of the visceral pleura. This also gives cancer cells a chance to get away from tumours. When the visceral pleura is cut, mesothelioma cells may also be able to metastasize, or spread to other parts of the body.
In a "non-incisional" P/D, doctors do not cut into the visceral pleura. Instead, they carefully peel it off the lung. This alternate approach may minimise the spread of tumour cells during P/D. As a result, "non-incisional" P/D may increase survival by reducing metastasis.
Doctors and researchers continue searching for ways to improve mesothelioma treatment. One of their efforts is "non-incisional" P/D.
The Pleurectomy and Decortication Procedure
Pleurectomy/decortication (P/D) is done in steps by surgeons. Pleurectomy and decortication are the two main parts of the procedure.
The surgical team takes precautions to protect important chest structures at each step of the two-part procedure. Four to six hours are required for the entire procedure.
The Pleurectomy Procedure
Depending on the patient and tumour characteristics, the surgical strategy may change. Generally, pleurectomy involves the following steps:
Health care providers prep the patient for surgery and administer general anaesthesia.
The patient moves to the operating room and lies on their side. This makes it easy to get to the ribs and chest structures.
A thoracotomy is the name given to the cut that the surgeon makes between the ribs.
The doctor takes out the sixth rib. This allows access to the pleural space.
The parietal pleura, or outermost layer of the pleura, is separated from surrounding structures by the surgeon. At this point, the parietal pleura may or may not be removed.
Tumors on the diaphragm or pericardium (the lining of the heart) must be removed. The surgeon will remove any cancerous parts of the diaphragm or pericardium at this stage.
The Decortication Process
During the pleurectomy part of the procedure, the parietal pleura is cut away from other structures. The parietal pleura may also be completely removed. In some cases, the surgeon may remove the parietal pleura during the decortication procedure. The following steps are typically involved in decor:
The visceral pleura is taken off by the surgeon (the layer of the pleura closest to the lungs).
Any tumour tissue that has grown into the lung tissue is also removed by the surgeon. In some cases, it may not be possible to remove tumour tissue from lung structures. The surgeon will do their best to remove as much cancer as possible.
Any lymph nodes that look like they might have cancer are removed by the surgeon.
If the surgeon removes part of the diaphragm, that part of the muscle will be rebuilt. The cancerous diaphragm tissue may be replaced with surgical mesh.
All cuts are closed by the surgeon.
After the cuts have been stitched back together, the patient can start to get better.
Recovery After mesothelioma Pleurectomy with Decortication
After a pleurectomy or decortication, the patient needs to spend time in the hospital and more time at home getting better. For immediate postoperative monitoring, the patient is frequently moved to the intensive care unit (ICU). The patient may become aware of a chest tube during this time.
During P/D or several days later, the surgeon may insert a chest tube. Chest tubes help alleviate fluid and air buildup in the chest. Once any air leaks have stopped, mesothelioma doctors can remove the chest tube.
Tests are also done by doctors to help keep an eye on the patient after surgery. A baseline chest X-ray and blood tests are among them. During recovery, patients may have multiple chest X-rays. These pictures help doctors keep track of how the patient is doing.
After surgery, patients may have to stay in the hospital for a few weeks or longer. After being discharged, recovery may take weeks to months.
Mesothelioma pleurectomy and decortication risks and side effects
Pleurectomy with decortication (P/D) is a surgical procedure that comes with risks. For example, surgeons anticipate moderate blood loss during any P/D procedure. Before beginning the procedure, the surgical team checks to see if there is donor blood available in case blood is lost.
Due to decortication, surgeons also expect significant air leaks. As small amounts of blood clot over them, the leaks can close on their own.
Common Side Effects of Pleurectomy with Decortication for mesothelioma
- Air leaks
- Blood loss
- Uneven heartbeats
- Pneumonia
- Respiratory failure
One journal article looked at the rates of complications in 12 P/D studies. More than 850 patients participated in these studies. Overall, the rates of complications for pleural mesothelioma in P/D ranged from 9 to 43%. But surgeons deal with these problems all the time, which may be why P/D has a low death rate.
In the aforementioned studies, the 30-day mortality rate ranged from 0% to 6.8%. The number of patients who pass away within 30 days of surgery is called the 30-day mortality rate. A 30-day mortality rate of 0 was reported in six of the 12 studies.
Thus, complications may arise, but surgeons handle them regularly and effectively.
Pleurectomy and Decortication: Benefits and Drawbacks for Pleural Mesothelioma
Pleural mesothelioma treatment with pleurectomy and decortication has a number of benefits. Advantages of pleurectomy/decortication for mesothelioma include:
Better short-term survival: In one study, P/D procedures resulted in only 1.7% short-term mortality. In the same study, EPP procedures led to a 4.5% short-term mortality rate. Thus, P/D may carry less than half the short-term mortality risk versus EPP. Short-term mortality is any death occurring within 30 days of P/D.
“Generally safer” status: P/D is thought to be safer than procedures that remove a lung because it does not remove the lung.
The patient's quality of life has improved because they still have both lungs after P/D. This could improve the quality of life more than treatments that take out one lung.
P/D patients still have both lungs after surgery, which means they can tolerate more therapy. Compared to patients who receive EPP, this might make them stronger and better able to handle additional treatment after surgery.
P/D may be more appropriate for some patients than other options, like EPP, due to its broad eligibility range.
P/D is the best surgery for pleural mesothelioma because of these and other reasons. But not all patients will be able to get P/D. Patients with pleural mesothelioma should talk to a specialist about surgery and other mesothelioma treatments. A specialist can help patients make the best decision for their unique situation.
Pleurectomy/Decortication and Extrapleural Pneumonectomy: What You Need to Know
According to study findings, about 20% of pleural mesothelioma patients have surgery. P/D and extrapleural pneumonectomy are the two main surgical options for that percentage of patients (EPP).
Many steps in both processes are similar. In fact, EPP can be thought of as P/D with the affected lung removed. Despite these similarities, the two methods are very different. Studies done recently show that EPP has a higher risk of complications and short-term mortality than P/D.
Despite being a more aggressive surgery, experts say EPP does not seem to increase survival compared to P/D. So, experts recommend P/D over EPP.
Mesothelioma survival after pleurectomy with decortication
Several variables affect the prognosis and prognosis of mesothelioma pleurectomy/decortication. Mesothelioma stage, treatment approach and patient characteristics can all affect survival. In studies of P/D and ePD for mesothelioma, the average time someone lives is between 10 and 57 months.
In one study, 90 people with pleural mesothelioma received multimodal therapy. Their treatment began with systemic chemotherapy, followed by P/D. After surgery, patients able to tolerate it received additional chemotherapy. Chemotherapy consisted of pemetrexed plus cisplatin or carboplatin.
In the study, the average length of survival was 57 months. The 1-year and 3-year survival rates were 93% and 65%, respectively.
Studies have also investigated P/D combined with photodynamic therapy and/or radiation. Additional P/D-based therapies are currently being investigated in clinical trials and other medical studies.
Eligibility for a Pleurectomy or Decortication
According to experts, P/D can be used successfully for the large majority of pleural mesothelioma cases.
In the past, experts thought of pleurectomy/decortication (P/D) as a treatment for pain relief. Palliative treatments try to ease symptoms and make life better for the patient. Palliative care doesn't try to kill or slow the growth of cancer.
Today, P/D still provides palliation. For surgical treatment of pleural mesothelioma, however, experts now advise P/D.
The best results from P/D treatment may be seen in patients who are diagnosed early. Experts have come up with a list of things that could make someone eligible for P/D:
- Mesothelioma tumours are only on one side of the body.
- P/D does not pose unreasonable risk to the patient.
- Patient has poor cardiopulmonary function and does not qualify for EPP.
- Patient has mesothelioma in its early stages and only has a few tumours.
- Patient has extensive mesothelioma that has spread to other important structures.
- Patient is more advanced in age.
- Some doctors might not give P/D to people who have certain traits. These characteristics include:
- Biphasic or sarcomatoid cell type
- lung-invasive tumours
- Understanding the Different Mesothelioma Cell Types
- Epithelioid, sarcomatoid, and biphasic cells are the three main types of cells that can develop mesothelioma. Biphasic is a mixture of epithelioid and sarcomatoid.