Extrapleural pneumonectomy (EPP) is a surgical procedure for treating pleural mesothelioma. It involves the removal of the impacted lung, portions of the diaphragm and the linings of the lung and heart (pleura and pericardium). The surgery is often part of a multimodal treatment plan with chemotherapy and radiation.

01. Defining Extrapleural Pneumonectomy

What Is an Extrapleural Pneumonectomy?

Extrapleural pneumonectomy (EPP) is a surgical procedure for pleural mesothelioma. It involves the removal of:

  • The diseased lung
  • Part or all of the diaphragm
  • A portion of the membrane covering the heart (pericardium)
  • Part of the membrane lining the chest cavity (parietal pleura)

The goal of the surgery is to achieve macroscopic complete resection. In other words, doctors aim to completely remove all visible cancer. As such, the surgery may improve survival for patients. It is often combined with other therapies, such as chemotherapy and radiation. These treatments may be administered before or after EPP.

EPP is often compared to another common surgery for pleural mesothelioma called pleurectomy/decortication (P/D).

Extrapleural Pneumonectomy vs. Pleurectomy/Decortication

Extrapleural pneumonectomy and pleurectomy/decortication (P/D) are two common therapeutic surgeries for pleural mesothelioma. Patients may undergo EPP or P/D in an effort to extend life expectancy.

P/D is sometimes referred to as a lung-sparing surgery. The procedure removes the cancerous tissue covering a lung without removing the entire lung. In this way, it is less aggressive than EPP.

P/D may also involve the removal of a part of the diaphragm and/or a portion of the lining of the heart (pericardium). When the diaphragm and/or pericardium is involved, the procedure is called an extended P/D.

Researchers continue to study EPP and P/D to determine the optimal treatment of malignant pleural mesothelioma. They examine the benefits and risks associated with each surgery. For many years, EPP was considered the only surgery that achieves the removal of all visible cancer. However, the technique of P/D has improved over time, leading to comparable survival versus EPP.

An increasing number of surgeons indicate a preference for P/D in the treatment of pleural mesothelioma because it is less invasive than EPP. However, no definitive clinical evidence favors one surgical procedure over the other.

02. How Does EPP Treat Mesothelioma?

How Does Extrapleural Pneumonectomy Treat Mesothelioma?

Extrapleural pneumonectomy treats pleural mesothelioma by attempting to remove all visible tumors. This outcome is known as macroscopic complete resection.

EPP is usually part of a multimodal approach to the treatment of malignant pleural mesothelioma. This means the surgery is combined with other therapies, such as chemotherapy and radiation. Other therapies may be administered before or after surgery depending on the patient’s case.

EPP Procedure

Extrapleural pneumonectomy is often completed at mesothelioma cancer centers by thoracic surgeons who specialize in performing the procedure.

For eligible patients, the EPP procedure steps include:

  • The patient is placed under general anesthesia.
  • The surgeon makes an incision to open the chest cavity. They may perform the surgery from the patient’s front, known as a sternotomy. Or, the surgeon may make an incision on the side, known as a thoracotomy. The incision is approximately nine inches.
  • After accessing the chest cavity, the surgeon resects the diseased lung, diaphragm, pericardium and pleura. The surgeon will remove as much cancerous tissue as possible.
  • When resection is complete, the diaphragm and pericardium are reconstructed with synthetic mesh material, such as Gore-Tex.

Patients are required to recover in the hospital for about two weeks after surgery. During this time, patients are monitored for potential complications.

03. Recovery

Recovery From Extrapleural Pneumonectomy

Extrapleural pneumonectomy is considered an extensive surgical procedure and requires a long recovery period. Typically, patients spend about two weeks recovering in a hospital. This recovery period is followed by additional time recovering at home.

The period of time patients spend in recovery depends on the scope of the surgery and the overall health of the patient. Some patients may require an additional 6 – 8 weeks following surgery to make a complete recovery.

While recovering in the hospital, the patient’s health care team will closely monitor them for any complications.

Before a patient is discharged from the hospital, the surgeon will provide specific instructions to follow during recovery at home. Instructions may include how to care for the surgical incision, when to resume normal activities and how to manage discomfort.

Patients may be advised to avoid certain activities, such as strenuous exercise, drinking alcohol and smoking. Patients will also be told when to return for the first follow-up visit.

04. Benefits

Benefits of Extrapleural Pneumonectomy

Extrapleural pneumonectomy may extend patient survival and improve quality of life for some patients with pleural mesothelioma.

In various clinical trials, researchers have reported a median survival of 12 – 20 months for mesothelioma patients who undergo EPP. Some studies have indicated longer survival times when EPP was administered in multimodal therapy. For instance, the combination of chemotherapy, EPP and then radiation therapy resulted in median mesothelioma survival times ranging from 12.8 to 46.9 months.

One study from 2020 indicated EPP may have a slightly higher rate of “long-term” cure compared to pleurectomy/decortication.

Research also suggests EPP may improve breathing and quality of life for some patients.

Pleural Mesothelioma Survivor Treated With EPP Outlives Prognosis by Years

In 2005, Heather Von St. James was diagnosed with pleural mesothelioma. She had an initial prognosis of 15 months. She traveled to Boston to undergo treatment with mesothelioma specialist Dr. David Sugarbaker. Heather underwent EPP surgery with heated chemotherapy. She also later underwent multiple rounds of chemotherapy and radiation. Today, Heather is a survivor of 17+ years, and she continues to advocate for the mesothelioma community.

05. Risks & Complications

Extrapleural Pneumonectomy Risks and Complications

As with any surgery, there are various risks and complications associated with extrapleural pneumonectomy. Complications can be short-term or long-term. Side effects of EPP can also vary in severity based on the individual patient’s case.

Side Effects of Extrapleural Pneumonectomy

  • Arrhythmia (abnormal heartbeat)
  • Blood clots
  • Bronchopleural fistula (abnormal connection between the airways in the lungs and the pleura)
  • Fluid buildup in the lungs
  • Infection
  • Internal bleeding
  • Pneumonia
  • Pus accumulation in the pleural space
  • Shortness of breath

Furthermore, researchers have found extrapleural pneumonectomy has a higher risk of complications and death compared to pleurectomy/decortication. According to one study, acute respiratory distress syndrome, bronchopleural fistula, irregular heartbeat and pneumonia were more common in EPP patients compared with P/D patients.

Some studies have also found the following potential disadvantages of EPP:

  • Extrapleural pneumonectomy may lead to a lower quality of life for some patients.
  • Patients may experience decreased cardiovascular function following surgery.
  • Patients may experience mesothelioma recurrence after surgery.
  • Patients may have a lower tolerance of chemotherapy following surgery, which may be recommended if cancer recurs.

Patients should talk to their doctors about all of the potential risks of this surgery and other treatment options for their individual cases.

06. Eligibility

Who Is Eligible for Extrapleural Pneumonectomy?

Not all pleural mesothelioma patients are candidates for EPP.

Because this surgery is considered aggressive, patients should also be in otherwise good health to be a candidate for EPP. Doctors will also consider the extent of tumors. For instance, patients with extensive tumor presence on lung tissue and/or tumors on the diaphragm or pericardium may be good candidates for EPP.

Doctors will also use the predicted lung function of the remaining lung after surgery to determine eligibility.

Certain criteria may make pleural mesothelioma patients ineligible for extrapleural pneumonectomy. For instance, patients with sarcomatoid mesothelioma are not considered good candidates. Patients with predicted lung function values below 30% are also considered high risk.

Patients who are not eligible for EPP may be eligible for pleurectomy/decortication or other therapies. Patients should discuss their eligibility for this surgery and other treatment options with their doctor.