{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T01:39:31Z","timestamp":1760060371788,"version":"build-2065373602"},"reference-count":38,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2025,8,23]],"date-time":"2025-08-23T00:00:00Z","timestamp":1755907200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>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\u201312.86; 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\u20136.93), 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\u20130.88; p = 0.027). Patients undergoing P\/D were, on average, 3.78 years older than those undergoing EPP (p &lt; 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.<\/jats:p>","DOI":"10.3390\/jcm14175964","type":"journal-article","created":{"date-parts":[[2025,8,25]],"date-time":"2025-08-25T00:09:53Z","timestamp":1756080593000},"page":"5964","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Pleurectomy\/Decortication Versus Extrapleural Pneumonectomy in Pleural Mesothelioma: A Systematic Review and Meta-Analysis of Survival, Mortality, and Surgical Trends"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0009-0006-4547-675X","authenticated-orcid":false,"given":"Margherita","family":"Brivio","sequence":"first","affiliation":[{"name":"Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Matteo","family":"Chiari","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Claudia","family":"Bardoni","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5330-5495","authenticated-orcid":false,"given":"Antonio","family":"Mazzella","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5986-7811","authenticated-orcid":false,"given":"Monica","family":"Casiraghi","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy"},{"name":"Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lorenzo","family":"Spaggiari","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy"},{"name":"Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1153-3334","authenticated-orcid":false,"given":"Luca","family":"Bertolaccini","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,8,23]]},"reference":[{"key":"ref_1","first-page":"260","article-title":"Diffuse pleural mesothelioma and asbestos exposure in the North Western Cape Province","volume":"17","author":"Wagner","year":"1960","journal-title":"Br. J. Ind. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"957","DOI":"10.1097\/JTO.0b013e31815608d9","article-title":"Prognostic factors in the treatment of malignant pleural mesothelioma at a large tertiary referral center","volume":"2","author":"Flores","year":"2007","journal-title":"J. Thorac. Oncol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"472","DOI":"10.1016\/j.athoracsur.2014.09.056","article-title":"Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma","volume":"99","author":"Taioli","year":"2015","journal-title":"Ann. Thorac. Surg."},{"key":"ref_4","first-page":"2569","article-title":"Physical function and health-related quality of life in patients undergoing surgical treatment for malignant pleural mesothelioma","volume":"25","author":"Tanaka","year":"2017","journal-title":"Support. Care Cancer"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Lauk, O., Patella, M., Neuer, T., Inci, I., Weder, W., and Opitz, I. (2021). Quality of Life Is Not Deteriorated After Extrapleural Pneumonectomy vs. (Extended) Pleurectomy\/Decortication in Patients with Malignant Pleural Mesothelioma. Front. Surg., 8.","DOI":"10.3389\/fsurg.2021.766033"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1775","DOI":"10.1016\/j.athoracsur.2015.01.058","article-title":"Effects of extended pleurectomy and decortication on quality of life and pulmonary function in patients with malignant pleural mesothelioma","volume":"99","author":"Burkholder","year":"2015","journal-title":"Ann. Thorac. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1900953","DOI":"10.1183\/13993003.00953-2019","article-title":"ERS\/ESTS\/EACTS\/ESTRO guidelines for the management of malignant pleural mesothelioma","volume":"55","author":"Scherpereel","year":"2020","journal-title":"Eur. Respir. J."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Danuzzo, F., Maiorca, S., Bonitta, G., and Nosotti, M. (2022). Systematic Review and Meta-Analysis of Pleurectomy\/Decortication versus Extrapleural Pneumonectomy in the Treatment of Malignant Pleural Mesothelioma. J. Clin. Med., 11.","DOI":"10.3390\/jcm11195544"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"457","DOI":"10.1016\/S2213-2600(24)00119-X","article-title":"Extended pleurectomy decortication and chemotherapy versus chemotherapy alone for pleural mesothelioma (MARS 2): A phase 3 randomised controlled trial","volume":"12","author":"Lim","year":"2024","journal-title":"Lancet Respir. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"139","DOI":"10.1016\/j.cct.2015.09.002","article-title":"Meta-analysis in clinical trials revisited","volume":"45","author":"DerSimonian","year":"2015","journal-title":"Contemp. Clin. Trials"},{"key":"ref_11","unstructured":"Team, R. (2021). RStudio: Integrated Development Environment for R, RStudio, Inc."},{"key":"ref_12","unstructured":"Team, R.C. (2021). R: A Language and Environment for Statistical Computing, R Foundation for Statistical Computing."},{"key":"ref_13","unstructured":"van Rossum, G. (1995). Python Reference Manual, CWI."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"298","DOI":"10.1016\/S1010-7940(02)00273-7","article-title":"The management of malignant pleural mesothelioma; single centre experience in 10 years","volume":"22","author":"Aziz","year":"2002","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"390","DOI":"10.1097\/JTO.0000000000000064","article-title":"Does surgery improve survival of patients with malignant pleural mesothelioma?: A multicenter retrospective analysis of 1365 consecutive patients","volume":"9","author":"Bovolato","year":"2014","journal-title":"J. Thorac. Oncol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"466","DOI":"10.1016\/1010-7940(91)90142-7","article-title":"Diagnostic and therapeutic strategy in malignant pleural mesothelioma","volume":"5","author":"Branscheid","year":"1991","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"434","DOI":"10.1016\/S1010-7940(03)00376-2","article-title":"Treatment of mesothelioma in Bloemfontein, South Africa","volume":"24","author":"Long","year":"2003","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"620","DOI":"10.1016\/j.jtcvs.2007.10.054","article-title":"Extrapleural pneumonectomy versus pleurectomy\/decortication in the surgical management of malignant pleural mesothelioma: Results in 663 patients","volume":"135","author":"Flores","year":"2008","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1348","DOI":"10.1016\/j.athoracsur.2021.04.042","article-title":"Japanese Current Status of Curative-Intent Surgery for Malignant Pleural Mesothelioma","volume":"113","author":"Hashimoto","year":"2022","journal-title":"Ann. Thorac. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1031","DOI":"10.1007\/s00595-021-02437-9","article-title":"Surgical strategy for malignant pleural mesothelioma: The superiority of pleurectomy\/decortication","volume":"52","author":"Kanayama","year":"2022","journal-title":"Surg. Today"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"2230","DOI":"10.21037\/tlcr-22-199","article-title":"Multimodal therapy of epithelioid pleural mesothelioma: Improved survival by changing the surgical treatment approach","volume":"11","author":"Klotz","year":"2022","journal-title":"Transl. Lung Cancer Res."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"740","DOI":"10.1093\/icvts\/ivw422","article-title":"Propensity matched comparison of extrapleural pneumonectomy and pleurectomy\/decortication for mesothelioma patients","volume":"24","author":"Kostron","year":"2017","journal-title":"Interact. Cardiovasc. Thorac. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1574","DOI":"10.1245\/s10434-022-12790-9","article-title":"Impact of Pleural Thickness on Occurrence of Postoperative Complications in Patients with Malignant Pleural Mesothelioma","volume":"30","author":"Ito","year":"2023","journal-title":"Ann. Surg. Oncol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"737","DOI":"10.1097\/JTO.0b013e31824ab6c5","article-title":"Pleurectomy\/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma","volume":"7","author":"Bille","year":"2012","journal-title":"J. Thorac. Oncol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"552","DOI":"10.1016\/j.ejcts.2009.07.032","article-title":"Three decades of experience in the surgical multi-modality management of pleural mesothelioma","volume":"37","author":"Luckraz","year":"2010","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"81","DOI":"10.5761\/atcs.oa.17-00192","article-title":"Is Pleurectomy\/Decortication Superior to Extrapleural Pneumonectomy for Patients with Malignant Pleural Mesothelioma? A Single-Institutional Experience","volume":"24","author":"Miyazaki","year":"2018","journal-title":"Ann. Thorac. Cardiovasc. Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1510\/icvts.2007.166322","article-title":"Radical surgery for malignant pleural mesothelioma: Results and prognosis","volume":"7","author":"Okada","year":"2008","journal-title":"Interact. Cardiovasc. Thorac. Surg."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e5","DOI":"10.1016\/j.cllc.2023.10.010","article-title":"Long-Term Survival Analysis of Pleural Mesothelioma Patients Undergoing Surgery: Brief Report From a Tertiary Referral Centre","volume":"25","author":"Orlandi","year":"2024","journal-title":"Clin. Lung Cancer"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"215","DOI":"10.1007\/BF02306613","article-title":"Surgically debulked malignant pleural mesothelioma: Results and prognostic factors","volume":"4","author":"Pass","year":"1997","journal-title":"Ann. Surg. Oncol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"2302114","DOI":"10.1183\/13993003.02114-2023","article-title":"A randomised phase II study of extended pleurectomy\/decortication preceded or followed by chemotherapy in patients with early-stage pleural mesothelioma: EORTC 1205","volume":"63","author":"Raskin","year":"2024","journal-title":"Eur. Respir. J."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1016\/j.lungcan.2011.12.009","article-title":"Extrapleural pneumonectomy for early stage malignant pleural mesothelioma: A harmful procedure","volume":"77","author":"Rena","year":"2012","journal-title":"Lung Cancer"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1722","DOI":"10.1016\/j.jtcvs.2022.11.035","article-title":"Pleurectomy and decortication are associated with better survival for bicavitary cytoreductive surgery for mesothelioma compared with extrapleural pneumonectomy","volume":"165","author":"Ripley","year":"2023","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1016\/j.athoracsur.2007.06.066","article-title":"Malignant pleural mesothelioma: Surgical management in 285 patients","volume":"85","author":"Schipper","year":"2008","journal-title":"Ann. Thorac. Surg."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1632","DOI":"10.1093\/ejcts\/ezv403","article-title":"The effects of an intentional transition from extrapleural pneumonectomy to extended pleurectomy\/decortication","volume":"49","author":"Sharkey","year":"2016","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1704","DOI":"10.1016\/j.jtho.2017.08.012","article-title":"National Cancer Database Report on Pneumonectomy Versus Lung-Sparing Surgery for Malignant Pleural Mesothelioma","volume":"12","author":"Verma","year":"2017","journal-title":"J. Thorac. Oncol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"200","DOI":"10.1016\/j.athoracsur.2021.04.078","article-title":"Extrapleural Pneumonectomy Versus Pleurectomy\/Decortication for Malignant Pleural Mesothelioma","volume":"113","author":"Zhou","year":"2022","journal-title":"Ann. Thorac. Surg."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1827","DOI":"10.1007\/s13304-022-01369-4","article-title":"Meta-analysis of survival after extrapleural pneumonectomy (EPP) versus pleurectomy\/decortication (P\/D) for malignant pleural mesothelioma in the context of macroscopic complete resection (MCR)","volume":"74","author":"Magouliotis","year":"2022","journal-title":"Updates Surg."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/17\/5964\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:34:49Z","timestamp":1760034889000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/17\/5964"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,8,23]]},"references-count":38,"journal-issue":{"issue":"17","published-online":{"date-parts":[[2025,9]]}},"alternative-id":["jcm14175964"],"URL":"https:\/\/doi.org\/10.3390\/jcm14175964","relation":{},"ISSN":["2077-0383"],"issn-type":[{"type":"electronic","value":"2077-0383"}],"subject":[],"published":{"date-parts":[[2025,8,23]]}}}