Extrapleural Pneumonectomy for Mesothelioma

What Is an Extrapleural Pneumonectomy?

Extrapleural pneumonectomy (EPP) is a surgical procedure that treats pleural mesothelioma by removing the affected lung, both layers of the lining around the lung (pleura), part or all of the diaphragm and any affected part of the lining around the heart (pericardium).

EPP was once a favored surgical approach for healthy patients with early-stage mesothelioma. Today, NCCN guidelines favor lung-sparing P/D for patients with stage 1, stage 2 or stage 3A mesothelioma and epithelioid cell type who are candidates for surgery. Current evidence shows P/D carries lower operative risks and has been associated with better survival than EPP. Doctors may still consider EPP in carefully selected patients when the size or location of the tumor makes it difficult to remove completely with P/D.

Treating Mesothelioma With Extrapleural Pneumonectomy

The goal of mesothelioma surgeries, including EPP, is to remove all visible cancer in a patient’s body. This can improve prognosis by minimizing the number of tumor cells.

EPP is usually part of a multimodal treatment plan. It is often combined with other therapies like chemotherapy and radiation. These treatments may be administered before or after EPP. Pre-surgery therapies are designed to boost the effectiveness of EPP. Post-surgery therapies help kill tumor cells left behind by EPP. Combination treatments that include EPP generally improve life expectancy better than EPP alone.

The Extrapleural Pneumonectomy Procedure

EPP is offered at mesothelioma cancer centers where thoracic surgeons often specialize in the procedure. Patients go under general anesthesia for an EPP. Then a surgeon accesses the chest cavity and removes as much tumor tissue as possible. This includes the linings of the lung and heart and affected parts of the diaphragm.

The procedure steps may vary between hospitals and surgeons. But EPP procedure steps generally include:

• The patient is placed under general anesthesia.
• The surgeon makes an incision to open the chest cavity (a thoracotomy). It usually goes from the chest, under the armpit and around to the patient’s back. In some cases, the surgeon may need to remove a rib to access the affected area.
• The surgeon removes tumors and some of the tissue around them. This includes the affected lung and the lining around it. The surgeon also takes out the sac around the heart (pericardium) and any cancerous parts of the diaphragm.
• The surgeon removes lymph nodes in the affected side of the chest.
• The surgeon repairs the diaphragm and pericardium with an implantable fabric.

Patients stay in the hospital for 1 – 2 weeks after surgery. Healthcare providers monitor patients closely during this time.

Recovery From Extrapleural Pneumonectomy

Immediately after surgery, patients need a great deal of care and assistance. Within weeks, they need less medical supervision and can continue recovering at home. So extrapleural pneumonectomy recovery happens in two stages:

• In-hospital: This stage happens right after surgery and usually lasts about 2 weeks.
• At-home: This stage begins after the patient is released from the hospital. It often takes 6 to 8 weeks, but some patients may need longer to feel recovered.

During the at-home recovery phase, patients may notice some changes in their bodies. They may feel more tired than usual or need to take breaks from physical activities. Patients may also have soreness or irritation in the operated area.

Experts say patients can ease the recovery process by closely following their doctors’ orders. This means avoiding doctor-prohibited activities and going to all check-up appointments. Patients can also benefit from consistently doing their physical therapy and breathing exercises.

Extrapleural Pneumonectomy Survival Rates and Prognosis

A 2025 meta-analysis of 24 studies found EPP patients had shorter median survival than P/D patients, by about 4 to 7 months on average. Earlier studies reported median survival of about 11 – 24 months after EPP. Many factors can affect survival, including patient health, tumor cell type, disease stage and other treatments received.

In the SMART protocol, developed at Princess Margaret Cancer Centre in Toronto, pleural mesothelioma patients received radiation targeted to the affected side of the chest, then had EPP surgery about one week later.

In a 2021 report on 96 patients treated with the SMART protocol, median survival was 24.4 months overall and 42.8 months for patients with epithelioid tumors. In general, epithelioid mesothelioma has a better prognosis than other cell types.

Patients can discuss the factors that influence EPP survival with their oncologists. Doctors can explain how individual and tumor characteristics may affect prognosis.

How Do Survival Rates for Extrapleural Pneumonectomy and Pleurectomy/Decortication Compare?

EPP and pleurectomy/decortication (P/D) are the primary surgical options for pleural mesothelioma. P/D is considered less aggressive than EPP because it does not remove the patient’s lung. For many years, this difference led people to believe EPP was the better option. But prognosis outcomes for EPP and P/D have changed this notion in recent years.

A 2025 meta-analysis pooling 24 studies found that people treated with P/D lived longer than those treated with EPP, by a pooled average of about 4 to 7 months. The survival difference is more pronounced in some individual studies than others.

For example, one research group looked at pleural mesothelioma patients treated with:

• EPP: This group received systemic chemotherapy + EPP + radiation.
• P/D: This group received P/D + HITHOC (heated chemo for the chest cavity) + systemic chemotherapy.

In one study, the EPP group had a median survival of 2 years, compared with just over 3 years for the P/D group. Results like these contributed to the recent shift in pleural mesothelioma surgery trends. In the past, EPP may have been more common. But over the last decade, P/D has overtaken EPP, becoming the more standard surgical option. The National Comprehensive Cancer Network now lists P/D as the preferred approach when surgery is appropriate.

Advantages of Extrapleural Pneumonectomy

EPP may improve survival and quality of life for some pleural mesothelioma patients. Potential benefits of EPP surgery include:

• Improve quality of life: When a tumor or fluid buildup is severely limiting lung function before surgery, removing the affected lung with EPP may ease breathing and improve quality of life.
• May help with difficult-to-remove tumors: Because EPP removes the affected lung, doctors may consider it when the size or location of the tumor makes complete removal difficult with lung-sparing surgery.

EPP may offer an advantage when mesothelioma has grown into areas of the lung that are difficult to remove with lung-sparing P/D. Because EPP removes the affected lung, surgeons may be able to remove more of the visible tumor in carefully selected patients.

Extrapleural Pneumonectomy Risks and Complications

As with any surgery, short- and long-term side effects are possible with EPP. Patient factors and treatment details can affect complication severity and duration.

Research indicates EPP surgeries carry higher risks than P/D surgeries. A 2025 meta-analysis of five studies with comparable data found the odds of dying within 30 days of surgery were about 2.8 times higher with EPP than P/D, an absolute difference of about 3 percentage points.

Other EPP disadvantages reported in medical literature include:

• Decreased heart-lung function: EPP can reduce a person’s heart-lung function. This can make breathing difficult and make patients feel more tired than normal.
• Potentially lower quality of life: Some patients may have a lower quality of life after EPP than before.
• Reduced tolerance for later cancer therapies: EPP can make patients less able to withstand treatments like chemotherapy. This may mean patients have fewer treatment options if mesothelioma comes back.

Interested patients should talk to their oncologists about the risks and benefits of EPP surgery. Experienced surgeons can explain how these considerations apply to a patient’s unique case.

Who Is Eligible for Extrapleural Pneumonectomy?

In the past, EPP was an option for healthy patients with resectable pleural mesothelioma. Today, P/D is generally preferred for most surgical candidates because evidence shows it has lower perioperative mortality and better survival than EPP. EPP may still be considered when the size or location of the tumor makes complete removal difficult with lung-sparing P/D. Patients must also be healthy enough to withstand surgery.

Doctors may consider lung function and tumor cell type when determining eligibility. Patients with expected post-surgery lung function of 40% or greater may be EPP candidates. Those with sarcomatoid tumors may not be candidates.

Patients who are not EPP candidates may be eligible for P/D or other treatments. Doctors can go over the treatment options and explain which might benefit an individual patient most.