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Malignant disease of the pleura encompasses a wide scope of clinical presentations ranging from asymptomatic simple pleural effusions to complex tumor masses involving multiple intrathoracic organs. The treatment options are similarly diverse. This chapter focuses on the indications, techniques, and results of pleurectomy and decortication (P/D) in the management of malignant pleural disease.

Pleural malignancies can be classified as primary, arising from the pleura, or secondary, that is, metastatic. Primary pleural malignancies include malignant pleural mesothelioma (MPM) and malignant localized fibrous tumors of the pleura. Metastatic pleural disease is a common clinical problem. Although lung and breast cancers are the most common primary tumors, virtually any cancer can metastasize to the pleura.

Although primary pleural tumors have been reported since the eighteenth century, the epidemiology of mesothelioma first came to light in 1960 with the report by Wagner and colleagues of 33 asbestos mine workers from South Africa who developed mesothelioma.1 Pleural mesothelioma previously was classified as benign or malignant. However, recognition that “benign” or “localized” mesothelioma has a biology that is distinct from MPM led to a change in nomenclature. These benign tumors are now termed solitary fibrous tumors of the pleura (see Chap. 109).

MPM is a rare tumor. Although the geographic distribution of the disease is diverse, taken as a whole, the United States has an incidence just under 1 per 100,000 persons.2 The incidence has been rising since the 1970s. The male-to-female ratio is 5:1, which is likely reflective of occupational exposure to asbestos.

The clinical presentation of MPM is usually insidious. The most common presenting symptoms are dyspnea and chest pain.

Staging in MPM, as is the case in other aspects of the disease, lacks consensus. Various staging systems exist. The classic system described by Butchart and colleagues in 1976 is relatively simple and descriptive.3 The Brigham staging system is based on resectability by extrapleural pneumonectomy (EPP; see Chap. 103) and may not be of value in patients undergoing P/D.4 The TNM staging system proposed by the International Mesothelioma Interest Group (IMIG) is the accepted American Joint Commission on Cancer staging system.5

Indications for Surgery

In the days before effective systemic therapy, MPM was thought to be uniformly fatal. Surgery was reserved for diagnosis and palliation. In the first reports of “curative” surgery, Butchart and colleagues (1976) performed EPP with a surgical mortality rate of 30%.3 In the nearly 30 years since the initial report, advances in patient selection, as well as intra- and postoperative management, have decreased the mortality of the operation substantially, as reported by centers with high volumes of mesothelioma surgery. Sugarbaker and colleagues reported their mortality rate from 183 consecutive EPPs performed at the Brigham and Women's Hospital as 3.8%.6 At Memorial Sloan-Kettering, we reported a 5.2% mortality for EPP.7 The staggeringly high mortality rate seen ...

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