Skip to main content

Updated meta-analysis of survival after extrapleural pneumonectomy versus pleurectomy/decortication in mesothelioma



We reviewed the available literature on patients with MPM undergoing either extrapleural pneumonectomy (EPP) or pleurectomy/decortication (P/D).


Original research studies that evaluated long-term outcomes of P/D versus EPP were identified, from January 1990 to July 2018. The 30 and 90 days mortality, along with the 1-, 2-, 3-, 5-year survival, the median overall survival and the complications were calculated according to both a fixed and a random effect model. The Q statistics and I2 statistic were used to test for heterogeneity among the studies.


Fifteen studies were included, incorporating a total of 1672 patients treated with EPP and 2236 treated with P/D. The 30-day mortality was significantly higher in the EPP group [OR 3.24 (95% CI 1.70, 6.20); p < 0.001]. The median overall survival was significantly increased in the P/D group [WMD − 4.20 (− 5.66, − 2.74); p < 0.001]. No significant differences were found regarding the 90-day mortality and the 1-, 2-, 3-, 5-year survival between the EPP and P/D groups. The incidence of postoperative atrial fibrillation, hemorrhage, empyema, bronchopleural fistula and air leak was significantly increased in the EPP group (p < 0.05).


The present meta-analysis indicates that P/D is associated with enhanced outcomes regarding 30-day mortality, median overall survival, and complications. The P/D approach, should, therefore be preferred when technically feasible. However, the decision regarding the procedure of choice should be made on the basis of the disease status and the surgeon’s experience. Well-designed, randomized studies, comparing EPP to P/D, are necessary to further assess their clinical outcomes.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2


  1. 1.

    Tural Onur S, Sokucu SN, Dalar L, Iliaz S, Kara K, Buyukkale S, et al. Are neutrophil/lymphocyte ratio and platelet/lymphocyte ratio reliable parameters as prognostic indicators in malignant mesothelioma? Ther Clin Risk Manag. 2016;12:651–6.

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Sugarbaker DJ, Wolf AS, Chirieac LR, Godleski JJ, Tilleman TR, Jaklitsch MT, et al. Clinical and pathological features of three-year survivors of malignant pleural mesothelioma following extrapleural pneumonectomy. Eur J Cardiothorac Surg. 2011;40:298–303.

    PubMed  Google Scholar 

  3. 3.

    Treasure T, Lang-Lazdunski L, Waller D, Bliss JM, Tan C, Entwisle J, et al. Extra-pleural pneumonectomy versus no extra-pleural pneumonectomy for patients with malignant pleural mesothelioma: clinical outcomes of the Mesothelioma and Radical Surgery (MARS) randomised feasibility study. Lancet Oncol. 2011;12:763–72.

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Rice D, Rusch V, Pass H, Asamura H, Nakano T, Edwards J, et al. Recommendations for uniform definitions of surgical techniques for malignant pleural mesothelioma: a consensus report of the international association for the study of lung cancer international staging committee and the international mesothelioma interest group. J Thorac Oncol. 2011;6(8):1304–12.

    Article  PubMed  Google Scholar 

  5. 5.

    Taioli E, Wolf AS, Flores RM. Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma. Ann Thorac Surg. 2015;99:472–80.

    Article  PubMed  Google Scholar 

  6. 6.

    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al., The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration, PLoS Med. 2009;6:e1000100.

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration; 2011 Accessed 12 July 2018.

  8. 8.

    Stang A. Critical evaluation of the Newcastle–Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25:603–5.

    Article  Google Scholar 

  9. 9.

    Aziz T, Jilaihawi A, Prakash D. The management of malignant pleural mesothelioma; single centre experience in 10 years. Eur J Cardiothorac Surg. 2002;22(2):298–305.

    Article  PubMed  Google Scholar 

  10. 10.

    Bovolato P, Casadio C, Billè A, Ardissone F, Santambrogio L, Ratto GB, et al. Does surgery improve survival of patients with malignant pleural mesothelioma? A multicenter retrospective analysis of 1365 consecutive patients. J Thorac Oncol. 2014;9(3):390–6.

    Article  PubMed  Google Scholar 

  11. 11.

    Branscheid D, Krysa S, Bauer E, Bülzebruck H, Schirren J. Diagnostic and therapeutic strategy in malignant pleural mesothelioma. Eur J Cardiothorac Surg. 1991;5(9):466–72 (discussion 473).

    Article  CAS  PubMed  Google Scholar 

  12. 12.

    de Vries WJ1, Long MA. Treatment of mesothelioma in Bloemfontein, South Africa. Eur J Cardiothorac Surg. 2003;24(3):434–40.

    Article  PubMed  Google Scholar 

  13. 13.

    Flores RM, Pass HI, Seshan VE, Dycoco J, Zakowski M, Carbone M, et al. Extrapleural pneumonectomy versus pleurectomy/decortication in the surgical management of malignant pleural mesothelioma: results in 663 patients. J Thorac Cardiovasc Surg. 2008;135(3):620–6, 626.e1–3.

    Article  PubMed  Google Scholar 

  14. 14.

    Kostron A, Friess M, Inci I, Hillinger S, Schneiter D, Gelpke H, et al. Propensity matched comparison of extrapleural pneumonectomy and pleurectomy/decortication for mesothelioma patients. Interact Cardiovasc Thorac Surg. 2017;24(5):740–6.

    Article  PubMed  Google Scholar 

  15. 15.

    Lang-Lazdunski L, Bille A, Lal R, Cane P, McLean E, Landau D, et al. Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma. J Thorac Oncol. 2012;7(4):737–43.

    Article  PubMed  Google Scholar 

  16. 16.

    Luckraz H, Rahman M, Patel N, Szafranek A, Gibbs AR, Butchart EG. Three decades of experience in the surgical multi-modality management of pleural mesothelioma. Eur J Cardiothorac Surg. 2010;37(3):552–6.

    Article  PubMed  Google Scholar 

  17. 17.

    Miyazaki T, Yamasaki N, Tsuchiya T, Matsumoto K, Kamohara R, Hatachi G, et al. Is pleurectomy/decortication superior to extrapleural pneumonectomy for patients with malignant pleural mesothelioma? A single-institutional experience. Ann Thorac Cardiovasc Surg. 2018;20(2):81–8.

    Article  Google Scholar 

  18. 18.

    Okada M, Mimura T, Ohbayashi C, Sakuma T, Soejima T, Tsubota N. Radical surgery for malignant pleural mesothelioma: results and prognosis. Interact Cardiovasc Thorac Surg. 2008;7(1):102–6.

    Article  PubMed  Google Scholar 

  19. 19.

    Pass HI, Kranda K, Temeck BK, Feuerstein I, Steinberg SM. Surgically debulked malignant pleural mesothelioma: results and prognostic factors. Ann Surg Oncol. 1997;4(3):215–22.

    Article  CAS  PubMed  Google Scholar 

  20. 20.

    Rena O, Casadio C. Extrapleural pneumonectomy for early stage malignant pleural mesothelioma: a harmful procedure. Lung Cancer. 2012;77(1):151–5.

    Article  PubMed  Google Scholar 

  21. 21.

    Schipper PH, Nichols FC, Thomse KM, Deschamps C, Cassivi SD, Allen MS, et al. Malignant pleural mesothelioma: surgical management in 285 patients. Ann Thorac Surg. 2008;85(1):257–64 (discussion 264).

    Article  PubMed  Google Scholar 

  22. 22.

    Sharkey AJ, Tenconi S, Nakas A, Waller DA. The effects of an intentional transition from extrapleural pneumonectomy to extended pleurectomy/decortication. Eur J Cardiothorac Surg. 2016;49(6):1632–41.

    Article  PubMed  Google Scholar 

  23. 23.

    Verma V, Ahern CA, Berlind CG, Lindsay WD, Sharma S, Shabason J, et al. National Cancer Database Report on pneumonectomy versus lung-sparing surgery for malignant pleural mesothelioma. J Thorac Oncol. 2017;12(11):1704–14.

    Article  PubMed  Google Scholar 

  24. 24.

    Cao C, Tian D, Park J, Allan J, Pataky KA, Yan TD, et al. A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma. Lung Cancer. 2014;83:240–5.

    Article  PubMed  Google Scholar 

  25. 25.

    Rusch V, Baldini EH, Bueno R, De Perrot M, Flores R, Hasegawa SJ. The role of surgical cytoreduction in the treatment of malignant pleural mesothelioma: meeting summary of the International Mesothelioma Interest Group Congress, September 11–14, 2012, Boston, Mass. Thorac Cardiovasc Surg. 2013;145(4):909–10.

    Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Dimitrios E. Magouliotis.

Ethics declarations

Conflict of interest

The authors declare no conflicts of interest.

Electronic supplementary material

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Magouliotis, D.E., Tasiopoulou, V.S. & Athanassiadi, K. Updated meta-analysis of survival after extrapleural pneumonectomy versus pleurectomy/decortication in mesothelioma. Gen Thorac Cardiovasc Surg 67, 312–320 (2019).

Download citation


  • Pleurectomy
  • Decortication
  • Extrapleural pneumonectomy
  • Malignant pleural mesothelioma