Extrapleural Pneumonectomy

What Is an Extrapleural Pneumonectomy?

Extrapleural pneumonectomy (EPP) is a surgical procedure that treats pleural mesothelioma. It removes:

• Both layers of the lining around the lung (the pleura)
• The affected lung
• Part or all of the diaphragm
• Any affected part of the lining around the heart (the pericardium)

In the past, candidates for EPP consisted only of patients in good health with early-stage mesothelioma. But new research has changed this. Patients with operable Stage 1, Stage 2 or Stage 3 mesothelioma generally undergo a different surgery. Doctors now generally reserve EPP for those with later-stage tumors that have spread from the pleura into the lung itself.

How Does Extrapleural Pneumonectomy Treat Mesothelioma?

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.

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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.

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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 occurs after the patient is released from the hospital. It often takes 1.5 – 3 months, 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

In studies, prognosis after EPP surgery with other therapies ranges from 11 to 51 months. The high end of this range is about 4 times the usual survival for mesothelioma treated with chemo alone. Many factors can influence prognosis after EPP. These include patient health, tumor cell type and treatment details.

In one study, pleural mesothelioma patients received multimodal treatment. First, they underwent radiation targeted to the affected lung. Then, within 5 days, they had EPP surgery.

Median survival for all study patients was about 2 years. But it was nearly 4 years for patients with epithelioid tumors. With EPP-based treatment, epithelioid tumors generally have better prognoses than other cell types.

_{Source: The Annals of Thoracic Surgery}

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 few trials have compared survival for mesothelioma patients treated with EPP or P/D surgeries. Study patients undergoing P/D lived 1 – 2 years longer than those undergoing EPP. The survival difference is more pronounced in some trials 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.

The EPP group had a median survival of 2 years. The P/D group had a median survival of just over 3 years. Results like these contributed to the recent shift in pleural mesothelioma surgery trends. In the past, EPP may have been more common. But in the last 5 – 10 years, P/D has overtaken EPP, becoming the more standard surgical option.

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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: EPP surgery may ease breathing problems, boosting quality of life.
• Helps with tumors that extend into the lung: EPP can remove mesothelioma cancer that has spread into the lung.
• May offer a better chance of long-term cure: EPP may have a slightly higher rate of long-term remission than P/D.

The main thing to keep in mind is that EPP may offer greater advantages for patients with more extensive tumors. For example, when mesothelioma cancer spreads into the lung, it can cause serious problems. P/D surgeries leave behind such tumors because they leave the lung in place. Since EPP removes the lung, it has a better chance of helping patients with this type of advanced tumor.

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. This includes risks for serious complications and death. Across studies, patients were more likely to die undergoing EPP compared to P/D. The risk of death with EPP was more than twice that of P/D in at least one trial.

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 eligibility was restricted to patients in good health with early-stage cancer. But EPP’s high risk of death and serious complications changed this. Currently, EPP is reserved for later-stage cancer patients with tumors that extend into the lung. They 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.