Pleurectomy/Decortication Versus Extrapleural Pneumonectomy in Pleural Mesothelioma: A Systematic Review and Meta-Analysis of Survival, Mortality, and Surgical Trends

Our plain-English summary of Pleurectomy/Decortication Versus Extrapleural Pneumonectomy in Pleural Mesothelioma: A Systematic Review and Meta-Analysis of Survival, Mortality, and Surgical Trends, by M. Brivio, M. Chiari, C. Bardoni, et al (Journal of Clinical Medicine, 2025).

The study

• Authors: M. Brivio, M. Chiari, C. Bardoni, A. Mazzella, M. Casiraghi, L. Spaggiari, L. Bertolaccini
• Journal: Journal of Clinical Medicine
• Published: 2025;14(17)
• Type of article: Review
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: The optimal surgical approach for malignant pleural mesothelioma (PM) remains a topic of debate. While extrapleural pneumonectomy (EPP) offers radical resection, it is associated with significant morbidity. Pleurectomy/decortication (P/D) is less extensive but may offer comparable oncologic outcomes with reduced perioperative risk. This study aimed to conduct a comprehensive systematic review and meta-analysis to systematically evaluate and quantitatively compare survival outcomes, 30-day postoperative mortality, and baseline characteristics between patients undergoing P/D and EPP for PM. Methods: A systematic review was conducted in accordance with the PRISMA guidelines. MEDLINE, Embase, and Scopus were searched up to May 2025. Studies comparing EPP and P/D in PM that reported on survival, mortality, or baseline demographics were included. Data from 24 retrospective studies were extracted. Pooled estimates were calculated using random-effects models. Meta-regression and subgroup analyses were performed by geographic region and publication year. Results: P/D was associated with a significantly improved overall survival compared to EPP in the primary analysis (mean difference = 7.01 months; 95% CI: 1.15-12.86; p = 0.018), with substantial heterogeneity (I2 = 98.5%). In a sensitivity analysis excluding one statistical outlier, the survival benefit remained significant (mean difference = 4.31 months; 95% CI: 1.69-6.93), and heterogeneity was markedly reduced. The 30-day mortality rate was also significantly lower for P/D (odds ratio = 0.34; 95% CI: 0.13-0.88; p = 0.027). Patients undergoing P/D were, on average, 3.78 years older than those undergoing EPP (p < 0.001), whereas no significant difference was observed in the sex distribution between groups. Subgroup analyses by region and publication year confirmed the robustness of the findings. Meta-regression did not reveal substantial modifiers of survival. Conclusions: P/D demonstrates superior overall survival and reduced perioperative mortality compared to EPP, without evidence of baseline demographic confounding. These findings, derived from retrospective comparative studies, support the preferential use of P/D in eligible patients, particularly in high-volume centers, given its favorable safety profile and superior median survival. However, the absence of randomized trials directly comparing P/D and EPP and the potential influence of patient selection warrant cautious interpretation, and surgical decisions should be tailored to individual patient factors within a multidisciplinary setting.

In plain English

Thoracic surgeons in Milan wrote this systematic review and meta-analysis. It compared extrapleural pneumonectomy (EPP), which removes the lung, pleura, pericardium and diaphragm, with lung-sparing pleurectomy/decortication (P/D) for pleural mesothelioma. The authors searched MEDLINE, Embase and Scopus up to May 2025 and pooled retrospective comparative studies covering 3943 patients. The review did not study asbestos exposure. Median overall survival was 7.01 months longer after P/D (95% CI 1.15 to 12.86), though studies varied widely. After one outlier study was excluded, the gap was 4.31 months (95% CI 1.69 to 6.93). Pooling five studies, the Results section found death within 30 days more likely after EPP (odds ratio 2.79, 95% CI 1.29 to 6.05). The abstract gives a different figure: 0.34 (95% CI 0.13 to 0.88) for P/D. P/D patients were on average 3.78 years older (95% CI 2.60 to 4.97). A statistical test suggested possible publication bias. The authors concluded that P/D was associated with better survival and lower early mortality. They cautioned that the evidence was retrospective, lacked randomized comparisons, and may have been affected by patient selection.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Systematic review and meta-analysis of retrospective comparative studies, following PRISMA guidelines, pooled with random-effects models
• Who was studied: Patients with pleural mesothelioma treated with EPP or P/D in 24 retrospective comparative studies (as the text states), totalling 3943 patients. The studies were published from 1991 to 2024 and came from Europe, Asia, the USA and South Africa. Databases were searched up to May 2025.
• Exposure: Not an asbestos exposure study. It compared two surgical procedures: EPP (removal of lung, pleura, pericardium and diaphragm) versus P/D (lung-sparing removal of the pleura).
• Main results:
  • Across studies, median overall survival was 7.01 months longer in P/D patients than in EPP patients (95% CI 1.15 to 12.86), with very high heterogeneity (I2 = 98.5%).
  • In a sensitivity analysis excluding one outlier study, the survival difference favoring P/D was 4.31 months (95% CI 1.69 to 6.93).
  • Results-section estimate: in five studies, 30-day postoperative mortality was higher with EPP than with P/D, with a pooled odds ratio of 2.79 (95% CI 1.29 to 6.05; p = 0.009) and an absolute difference of 3.24 percentage points. The article's abstract instead gives an odds ratio of 0.34 (95% CI 0.13 to 0.88) for P/D, which is not the exact reciprocal of 2.79.
  • In nine studies, P/D patients were on average 3.78 years older than EPP patients (95% CI 2.60 to 4.97).
  • In six studies, women made up 14.2% of the EPP group and 18.2% of the P/D group.
  • Among 15 studies, the share of patients receiving P/D rose over time (slope 0.55% per year).
  • In a meta-regression of nine studies, the survival advantage of P/D was larger in studies with younger patients.
  • Egger's test showed funnel plot asymmetry (p = 0.012), suggesting possible small-study effects or publication bias in the survival analysis.
• The authors' conclusion: The authors concluded that, in retrospective series often from high-volume centers, P/D is associated with lower perioperative risk and better median survival than EPP, and may be the preferred option when technically feasible. They added that the evidence is observational, that randomized trials comparing the two operations are lacking, and that surgical decisions should be individualized.
• Limitations the authors state:
  • All data came from retrospective studies and are subject to selection bias in who received which operation.
  • The analysis could not adjust for prognostic factors such as histological subtype, performance status or lung function.
  • Perioperative outcomes and complications were inconsistently defined and reported.
  • Pooling differences in median survival does not account for censoring or follow-up, so it is only an approximation.
  • Possible publication bias: smaller studies may have reported more favorable results for P/D.
  • Substantial unexplained heterogeneity remained.
  • The search excluded non-English studies and some databases.
  • No randomized trials directly compared P/D and EPP.
  • Underrepresentation of North American cohorts limited geographic subgroup analysis.

Topics

Medical terms in this study, explained in our Lexicon: Pleurectomy/Decortication (P/D), Extrapleural Pneumonectomy (EPP), Pleural Mesothelioma, Systematic Review, Meta-Analysis, Overall Survival, Odds Ratio, Confounding.

Related studies

• Systematic Review and Meta-Analysis of Pleurectomy/Decortication versus Extrapleural Pneumonectomy in the Treatment of Malignant Pleural Mesothelioma — F. Danuzzo, S. Maiorca, et al. (2022)
• Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma — E. Taioli, A.S. Wolf, et al. (2015)
• Extrapleural Pneumonectomy Versus Pleurectomy/Decortication for Malignant Pleural Mesothelioma — N. Zhou, D.C. Rice, et al. (2022)
• Current Treatment of Mesothelioma: Extrapleural Pneumonectomy Versus Pleurectomy/Decortication — A.S. Wolf, R.M. Flores (2016)
• Systematic review of quality of life following pleurectomy decortication and extrapleural pneumonectomy for malignant pleural mesothelioma — R.M. Schwartz, W. Lieberman-Cribbin, et al. (2018)
• Extrapleural Pneumonectomy and Pleurectomy Decortication: Can We Really Compare Their Survival? — P. Bertoglio, S. Korasidis (2015)

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