Mesothelioma Surgery Options 2026: EPP vs P/D and Emerging Techniques

Surgery remains the cornerstone of treatment for mesothelioma patients who are healthy enough to undergo major operations. The two primary surgical approaches for pleural mesothelioma—extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D)—offer different trade-offs between tumor removal and lung preservation [1]. At experienced centers, surgical patients achieve median survival times of 18-24 months, with some patients surviving 5 years or longer [2].

Executive Summary

Mesothelioma surgery has evolved significantly over the past two decades, with pleurectomy/decortication (P/D) now preferred at most centers due to lower operative mortality (2-4% vs 5-7% for EPP) and comparable survival outcomes [1]. The choice between EPP and P/D depends on tumor extent, patient fitness, and surgeon expertise. For peritoneal mesothelioma, cytoreductive surgery with HIPEC achieves remarkable 5-year survival rates of 50-69% at high-volume centers [3]. Emerging techniques combining surgery with immunotherapy are showing promising results, with 80% surgical completion rates and extended survival [5]. Choosing an experienced surgical team at a specialized mesothelioma treatment center is critical—surgical outcomes vary significantly based on center volume.

10 Key Facts About Mesothelioma Surgery in 2026

Surgical Mortality (P/D): 2-4% at experienced centers [1]
Surgical Mortality (EPP): 5-7% at experienced centers [1]
P/D Median Survival: 18-24 months with multimodal treatment [2]
CRS-HIPEC 5-Year Survival: 50-69% for peritoneal mesothelioma [3]
Surgical Candidacy: Approximately 20-25% of patients qualify
Hospital Stay: 7-14 days for major procedures
Recovery Time: 2-4 months to full activity
Center Volume Matters: High-volume centers have 40% lower mortality [4]
Perioperative Immunotherapy: 80% surgical success rate in trials [5]
Best Outcomes: Epithelioid type, early-stage, multimodal treatment

What Are the Main Surgical Options for Pleural Mesothelioma?

Two major surgical procedures treat pleural mesothelioma: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). Understanding the differences helps patients make informed decisions with their surgical team.

Extrapleural Pneumonectomy (EPP)

EPP is the more radical procedure, removing multiple structures from the affected side of the chest:

Entire lung: Complete removal of the diseased lung
Parietal pleura: Lining of the chest wall
Visceral pleura: Lining covering the lung
Pericardium: Membrane surrounding the heart (partially)
Diaphragm: The breathing muscle (ipsilateral portion)

The goal of EPP is macroscopic complete resection—removing all visible tumor [1]. The diaphragm and pericardium are reconstructed with synthetic patches.

5-7%

Surgical mortality rate for EPP at experienced centers

EPP may be preferred when:

Tumor extensively involves the lung tissue
Fissures between lung lobes are invaded
Complete removal requires lung sacrifice
Patient has adequate pulmonary reserve in the remaining lung

Pleurectomy/Decortication (P/D)

P/D removes the diseased pleural lining while preserving the lung itself:

Parietal pleura: Complete removal of chest wall lining
Visceral pleura: Stripping of the tumor from the lung surface
Visible tumor nodules: Removal from chest wall, diaphragm, pericardium
Lung preservation: The underlying lung remains intact

Extended P/D may include diaphragm and/or pericardium resection when involved by tumor, similar to EPP but without lung removal.

"The shift toward lung-sparing surgery has been one of the most significant changes I've seen in mesothelioma care. Patients recover faster, maintain better breathing capacity, and—importantly—the survival numbers are comparable. But the right surgery depends on the individual case, which is why choosing an experienced team matters so much."
— David Foster, Executive Director of Client Services, Danziger & De Llano

How Do EPP and P/D Compare in 2026?

The debate between EPP and P/D has evolved significantly, with most major centers now favoring lung-sparing surgery [1].

Survival Outcomes

Factor	EPP	P/D
Median Survival	15-20 months	18-24 months
30-Day Mortality	5-7%	2-4%
Major Complications	50-60%	25-35%
Hospital Stay	10-14 days	7-10 days
Recovery Time	3-4 months	2-3 months

Quality of Life

P/D generally offers better quality of life outcomes:

Preserved lung function: Patients retain more breathing capacity
Faster recovery: Return to normal activities sooner
Lower complication rates: Fewer postoperative problems
Better exercise tolerance: Ability to maintain physical activity

When EPP May Still Be Preferred

Despite the trend toward P/D, EPP remains appropriate in specific situations:

Extensive involvement of the lung parenchyma
Tumor invasion into the fissures
When complete resection is not possible with P/D
Younger, fit patients with excellent contralateral lung function

Who Is a Candidate for Mesothelioma Surgery?

Not all mesothelioma patients are surgical candidates. Approximately 20-25% of patients qualify for potentially curative surgery [2].

Favorable Factors for Surgery

Epithelioid histology: Best-responding cell type to surgery
Early stage (I-III): Disease confined to one side of the chest
Good performance status: ECOG 0-1 (active, able to care for self)
Adequate pulmonary function: FEV1 >1.5L or >40% predicted
Cardiac health: Ability to tolerate major surgery
No distant metastases: Cancer hasn't spread to other organs

Factors That May Preclude Surgery

Sarcomatoid histology: Aggressive type with poor surgical outcomes
Advanced stage (IV): Distant spread or contralateral disease
Poor performance status: Unable to tolerate major surgery
Significant comorbidities: Heart disease, COPD, kidney failure
Inadequate pulmonary reserve: Wouldn't tolerate lung removal (for EPP)

20-25%

Percentage of mesothelioma patients who are surgical candidates

The Importance of Staging

Accurate staging is essential before surgery. Staging workup typically includes:

CT scan: Detailed chest imaging
PET scan: Identifies distant spread
MRI: Evaluates chest wall and diaphragm involvement
Mediastinoscopy: Sampling of lymph nodes
Pulmonary function tests: Assesses breathing capacity
Cardiac evaluation: Ensures heart can tolerate surgery

Learn more about understanding your mesothelioma diagnosis and staging.

What Is CRS-HIPEC Surgery for Peritoneal Mesothelioma?

Cytoreductive surgery with heated intraperitoneal chemotherapy (CRS-HIPEC) has transformed outcomes for peritoneal mesothelioma [3].

The CRS-HIPEC Procedure

CRS-HIPEC is a two-part procedure performed during a single operation:

Cytoreductive surgery (CRS): Removal of all visible tumor from the abdominal cavity, including peritoneum, omentum, and involved organs if necessary
HIPEC: Heated chemotherapy (typically cisplatin or mitomycin C at 41-42°C) is circulated through the abdomen for 60-90 minutes

The heat enhances chemotherapy penetration and directly kills remaining microscopic cancer cells.

CRS-HIPEC Outcomes

At experienced centers, CRS-HIPEC achieves remarkable results [3]:

5-year survival: 50-69% (vs. 18% with systemic therapy alone)
Median survival: 53-92 months at high-volume centers
Complete cytoreduction: Critical factor—correlates with best outcomes
Operative mortality: 1-4% at experienced centers

"CRS-HIPEC is one of the great success stories in mesothelioma treatment. I've worked with peritoneal patients who are now 7, 8, even 10 years out from their surgery. But the key word is 'experienced center'—these are complex 8-12 hour operations that require specialized teams."
— David Foster, Executive Director of Client Services, Danziger & De Llano

Peritoneal Mesothelioma Surgical Candidacy

Factors favoring CRS-HIPEC success:

Epithelioid cell type
Limited peritoneal cancer index (PCI) score
No extra-abdominal spread
Good nutritional status
Ability to achieve complete cytoreduction (CC-0 or CC-1)

What Emerging Surgical Techniques Are Available in 2026?

Mesothelioma surgery continues to evolve with new techniques and combination approaches.

Perioperative Immunotherapy

Combining surgery with immunotherapy—given before and/or after the operation—is showing promising results [5]:

Neoadjuvant immunotherapy: Checkpoint inhibitors before surgery
80% surgical completion rate: In perioperative trials
28.6-month median survival: Johns Hopkins trial results
Improved pathologic response: More tumor cell death at surgery

Photodynamic Therapy (PDT)

PDT uses light-activated drugs to kill remaining cancer cells after surgical resection:

Photosensitizing drug administered before surgery
Special light applied to surgical cavity
Activates drug to destroy residual tumor cells
Being studied in combination with P/D

Tumor Treating Fields (TTFields)

TTFields uses electrical fields to disrupt cancer cell division and is now FDA-approved for use with chemotherapy. Research is evaluating its role in post-surgical treatment.

Intraoperative Chemotherapy Techniques

Beyond HIPEC for peritoneal disease, researchers are studying:

Intrapleural chemotherapy: Direct delivery during thoracic surgery
Pressurized aerosol chemotherapy (PIPAC): Nebulized drug delivery
Hyperthermic intrathoracic chemotherapy (HITHOC): Heated chemo for pleural disease

Why Does Surgical Center Experience Matter?

Mesothelioma surgery outcomes vary dramatically based on where the operation is performed [4].

High-Volume vs. Low-Volume Centers

Factor	High-Volume Center	Low-Volume Center
Operative Mortality	2-4%	8-12%
Complication Rates	25-35%	45-60%
Complete Resection Rate	75-85%	50-65%
Long-Term Survival	Significantly better	Reduced

What Makes a High-Volume Center?

Case volume: 20+ mesothelioma surgeries per year
Dedicated mesothelioma team: Specialized surgeons, oncologists, pathologists
Multidisciplinary approach: Regular tumor board discussions
Clinical trial access: Latest treatment options
Support services: Palliative care, nutrition, rehabilitation

Leading Mesothelioma Surgical Centers

Centers known for mesothelioma surgical excellence include:

Brigham and Women's Hospital — Boston, MA
MD Anderson Cancer Center — Houston, TX
Memorial Sloan Kettering — New York, NY
Mayo Clinic — Rochester, MN
Moffitt Cancer Center — Tampa, FL
University of Pennsylvania — Philadelphia, PA

"I've been coordinating care for mesothelioma patients for 18 years, and I always emphasize: travel if you need to. A few hundred miles can mean the difference between a center that does 2 mesothelioma surgeries a year and one that does 50. That experience translates directly into better outcomes."
— David Foster, Executive Director of Client Services, Danziger & De Llano

What Should You Expect During Recovery?

Understanding the recovery process helps patients and families prepare.

Hospital Stay

P/D: 7-10 days typical hospital stay
EPP: 10-14 days typical hospital stay
CRS-HIPEC: 10-14 days typical hospital stay
ICU time: 1-3 days for major procedures

Early Recovery (Weeks 1-4)

Chest tubes for drainage (removed within first week typically)
Pain management with oral medications
Walking and light activity encouraged
Breathing exercises to prevent pneumonia
Gradual increase in diet

Later Recovery (Months 1-3)

Gradual return to normal activities
Pulmonary rehabilitation for EPP patients
Follow-up imaging to assess results
Discussion of adjuvant treatment (chemotherapy, radiation)
Quality of life typically returns to baseline by 6 months

Frequently Asked Questions

What is the difference between EPP and P/D surgery for mesothelioma?

Extrapleural pneumonectomy (EPP) removes the entire lung along with the pleura, diaphragm, and pericardium. Pleurectomy/decortication (P/D) removes the diseased pleural lining while preserving the lung. P/D has become preferred at most centers due to lower mortality rates (2-4% vs 5-7%) and faster recovery while achieving similar survival outcomes.

What is the survival rate for mesothelioma surgery?

Survival rates vary by procedure and patient factors. P/D surgery combined with chemotherapy achieves median survival of 18-24 months, with 5-year survival rates of 12-20% in optimal candidates. Peritoneal mesothelioma patients undergoing CRS-HIPEC can achieve 5-year survival rates of 50-69% at experienced centers.

Who is a candidate for mesothelioma surgery?

Surgical candidates typically have epithelioid cell type, early-stage disease (Stage I-III), good overall health (ECOG 0-1), adequate heart and lung function, and no distant metastases. Age alone doesn't disqualify patients—overall fitness matters more than chronological age.

How long is recovery from mesothelioma surgery?

Hospital stays typically range from 7-14 days for major mesothelioma surgery. Full recovery takes 2-3 months for P/D and 3-4 months for EPP. Many patients begin chemotherapy 4-6 weeks after surgery. Quality of life typically returns to baseline within 6 months.

What is CRS-HIPEC surgery for peritoneal mesothelioma?

Cytoreductive surgery with heated intraperitoneal chemotherapy (CRS-HIPEC) is the gold standard for peritoneal mesothelioma. Surgeons remove all visible tumor, then circulate heated chemotherapy through the abdomen to kill remaining cancer cells. This procedure achieves 5-year survival rates up to 69%.

Does mesothelioma surgery cure the cancer?

Surgery alone rarely cures mesothelioma, but it can significantly extend survival and improve quality of life. Most patients receive multimodal treatment combining surgery with chemotherapy and/or immunotherapy. Some patients achieve long-term survival of 5+ years with aggressive surgical treatment.

Next Steps: Evaluating Your Surgical Options

If you've been diagnosed with mesothelioma, understanding your surgical options is an essential part of treatment planning. The best approach depends on your specific diagnosis, overall health, and treatment goals.

Our patient advocacy team can help connect you with experienced mesothelioma surgical centers and specialists who perform these procedures regularly. We believe every patient deserves access to the most advanced surgical care available.

Related Resources

Top 6 Mesothelioma Treatment Centers 2026 — Leading surgical programs
Clinical Trials 2026 — Emerging treatment options
Find Mesothelioma Specialists — Connect with experts nationwide
Free Case Assessment — Get personalized guidance

Learn More About Treatment

Treatment Options — Complete treatment guide
Treatment Centers — Specialized facility information
Survival Statistics — Prognosis and outcome data

Sources:

Journal of Thoracic Oncology. (2025). Comparative Outcomes of EPP versus P/D for Malignant Pleural Mesothelioma.
National Comprehensive Cancer Network. (2026). NCCN Guidelines for Malignant Pleural Mesothelioma.
Annals of Surgical Oncology. (2025). CRS-HIPEC Outcomes: Multi-Institutional Analysis.
Journal of Clinical Oncology. (2025). Surgical Mortality Trends in Mesothelioma: 2000-2025.
Lancet Oncology. (2025). Perioperative Immunotherapy in Mesothelioma Surgery.

Last updated: January 28, 2026