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Malignant disease of the pleura presents clinically in a variety of ways, 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 dichotomized as either primary or secondary; primary pleural malignancy arises from the pleura and secondary represents metastasis from other sites (such as lung, breast, or colon). 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 et al.1 of 33 asbestos mine workers from South Africa who developed mesothelioma. Pleural mesothelioma previously was classified as benign or malignant. However, recognition that “benign” or “localized” mesothelioma has a biology that is distinct from malignant pleural mesothelioma (MPM) led to a change in nomenclature. The benign tumor seen in localized mesothelioma is now termed solitary fibrous tumor of the pleura.

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, most commonly manifesting initially with dyspnea and/or 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 et al. in 1976 is relatively simple and descriptive.3 The Brigham staging system is based on resectability by extrapleural pneumonectomy (EPP) and may not be of value in patients undergoing P/D.4 The tumor, node, metastasis (TNM) staging system proposed by the International Mesothelioma Interest Group (IMIG) is the accepted American Joint Commission on Cancer staging system.5 These staging systems and modern updates based on more recent studies and improved understanding of clinical staging and more accurate predictors of prognosis are discussed in more detail in Chapter 119.

Indications for Surgery

In the days before adjuvant therapy, MPM was thought to be uniformly fatal. Surgery was reserved for diagnosis and palliation. In the first reports of “curative” surgery, Butchart et al.3 performed EPP with a surgical mortality rate of 30%. In the 40 years since the initial report, advances ...

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