Extrapleural pneumonectomy (EPP) is a surgical procedure that treats pleural mesothelioma. It removes the impacted lung, the linings of the lung and heart, and the diaphragm. EPP is usually part of a multimodal treatment plan. Patients often receive chemo and radiation after surgery.

01. Overview of EPP

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. This means patients undergo EPP and at least one other treatment.

EPP 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.

02. Steps in the EPP Procedure

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.

03. Recovery After EPP

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.

A Mesothelioma Survivor's Perspective on Recovery After Extrapleural Pneumonectomy

Heather Von St. James had an EPP surgery in early 2006. Some of the challenges she faced related to unrealistic expectations about recovery. Her surgeon told her she would be “back behind the chair, working in the salon” within 3 months of surgery. Heather’s experience was quite different.

“I was still like an infant [at that point]. I could hardly function. There was no way I could work a full-time job out of the house.”

Heather says recovery takes much longer than you think it will. So it’s important to be patient, trust the process and not rush it.

04. Prognosis After EPP

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.

Pleural Mesothelioma Survival Rates After EPP With or Without Other Treatments

1-Year Survival 2-Year Survival 3-Year Survival
EPP surgery 52% 34% 21%
Chemo + EPP 56% 29% 17%
EPP + radiation 66% 39% 22%
Chemo + EPP + radiation 76% 51% 37%

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.

05. Benefits of EPP

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.

Pleural Mesothelioma Survivor Treated With EPP Outlives Prognosis by More Than a Decade

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 18+ years, and she continues to advocate for the mesothelioma community.

06. Complications & Risks of EPP

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.

Potential Complications 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

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.

07. Eligibility for EPP

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.

08. Common Questions

Common Questions About Extrapleural Pneumonectomy for Mesothelioma

What is the difference between pleurectomy and extrapleural pneumonectomy?

Pleurectomy/decortication (P/D) surgery removes the lining around the lung. It may also remove cancerous parts of the diaphragm and the sac around the heart. Extrapleural pneumonectomy (EPP) does the same and removes the entire lung on the affected side. EPP is a more aggressive surgery for patients with tumors that have spread to their lungs.

What is a patient’s life expectancy after an extrapleural pneumonectomy?

In mesothelioma studies, life expectancy after EPP ranges from 11 to 51 months. The upper end of this range is about 4 times the survival of pleural patients treated only with chemo. Prognosis depends on patient factors, tumor cell type and treatment details. EPP-based therapy combos tend to extend survival better than EPP alone.

How much does an extrapleural pneumonectomy cost?

A recent study found the average cost of extrapleural pneumonectomy was $62,408 in 2014. In 2023, this would amount to about $82,000. Some or all of this cost may be covered by insurance, depending on a person’s policy.

Mesothelioma patients may have other options for covering treatment costs. Asbestos lawsuits and trust fund claims can provide compensation for people injured by asbestos exposure. Patients interested in these options should speak to a mesothelioma attorney.