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Mesothelioma Pneumonectomy

Mesothelioma pneumonectomy is a curative surgical treatment for pleural mesothelioma patients. The surgery is a less invasive procedure than extrapleural pneumonectomy, the other common curative pleural mesothelioma surgery.

A pneumonectomy procedure involves the removal of a pleural mesothelioma patient’s cancerous lung. There are two forms of pneumonectomy: a traditional pneumonectomy, removing only the cancerous lung, or an extrapleural pneumonectomy (EPP), which removes the entire lung, pleural linings and more. A traditional pneumonectomy, while less invasive than extrapleural pneumonectomy, is a major procedure and is typically only performed on patients with early-stage disease who are best able to recover from the surgery. Performed on the proper patient, a pneumonectomy can increase patient survival.

How Pneumonectomy Treats Mesothelioma

For malignant pleural mesothelioma patients, a pneumonectomy procedure may be administered to remove any existing cancer and prevent metastasis. The treatment is most often suggested for patients in good health. A pneumonectomy is most successful when performed on patients with early-stage disease that is still localized within a single lung.

A traditional pneumonectomy surgery, to remove the cancerous lung, takes several hours to complete and is performed under general anesthesia. A mesothelioma specialist will make an incision several inches long between the ribs. The incision extends under the arm and around the back to the side where the diseased lung will be removed. After the incision has been made, the thoracic surgeon gently separates the ribs to get a clear view of the cancerous lung. A patient’s sixth rib may be removed to gain adequate access to the lung. Once accessed, the lung will be deflated for removal from the chest cavity. During surgery, surrounding lymph nodes may also be removed to aid in staging the disease.

The surgical procedure has shown the most favorable results when administered as part of a multimodality treatment approach. Because a pneumonectomy is a form of macroscopic complete resection (MCR), meaning the surgery removes all cancer visible to the naked eye, there may be some microscopic cancer cells left within the body. As there is no mesothelioma surgery capable of complete microscopic resection (cancer visible under a microscope), combining surgery with chemotherapy or radiation therapy has shown to be most effective in eliminating cancer cells.

The efficacy of a multimodal approach for patients with lung cancers is evident in a retrospective study analyzing 100 patients who underwent pneumonectomy for non-small cell lung cancer (NSCLC) between 1998 and 2009. The researchers found 60% of patients who had the surgical procedure with adjuvant therapy (either radiation, chemotherapy or both) achieved 5-year survival. Comparatively, only 30% of patients who received pneumonectomy alone survived for five years following treatment.

For certain pleural mesothelioma patients, the procedure can be performed with less risk through use of video technology. Pleural mesothelioma patients whose tumor(s) are on the edges of the lung and in the very early stages of disease may be eligible for a pneumonectomy performed using video-assisted thoracoscopic surgery (VATS). A pneumonectomy performed this way uses a video camera to enable a smaller incision, making the surgery less invasive and expediting recovery. However, a VATS pneumonectomy should only be completed by a surgeon with expertise and skill performing the specific procedure.

Eligibility for Mesothelioma Pneumonectomy

Because a pneumonectomy is an invasive, aggressive treatment, it is not a viable option for many patients. To be eligible for a pneumonectomy, patients must be in good overall health because the removal of one lung will put extra strain on the heart and remaining lung. A patient’s healthcare team may use imagining scans and pulmonary function tests to ensure proper patient selection. A thoracic surgeon will look at these test results to determine if a patient's lung function in their remaining lung is strong enough to perform necessary respiratory functions should the cancerous lung be removed.

Additionally, older patients may be ineligible for a pneumonectomy. According to a 2017 study, patients aged 55 years old and older who underwent a pneumonectomy were at greater risk of complications. Researchers found patients who were 55 or older had a 5-year survival rate of just 15.2%. Patients under 55 years old had a 5-year survival rate of 54%. Unfortunately, due to the long latency period of mesothelioma cancer, many pleural mesothelioma patients are not diagnosed until later in life and may not be eligible for a pneumonectomy. Older patients are also more likely to have other pre-existing health conditions, which could impact their eligibility for certain treatment options.

Regardless of age, patients may be ineligible for pleural mesothelioma treatment with a pneumonectomy based on which of their lungs is cancerous. Eligibility may be impacted if a patient's affected lung is on the right side. Studies have shown patients with mesothelioma of the right lung often have less favorable results following mesothelioma surgery. Complications arise due to the location and complicated dissection of the paratracheal mediastinum (lymph nodes within the chest). This dissection causes greater risk of a brochopleural fistula, an abnormal sinus tract that develops between the airways in the lung (bronchi) and the pleural space, which may be fatal.

One study analyzing data from more than 2,000 patients found a right side pneumonectomy resulted in a 30-day mortality rate of 9.6%, while a left side pneumonectomy had a 30-day mortality rate of only 3.3%. Patients with mesothelioma on the right side may be best served with other treatment modalities, mitigating risks of complications following a pneumonectomy.

Side Effects and Risks of Pneumonectomy

Like any major surgery, there are risks associated with a pneumonectomy, and for some patients, recovery may be long and painful. A hospital stay of several days, and in some cases up to two weeks, may be required depending on a patient’s specific case. After release from the hospital, it may take one to two months for a patient to make a full recovery from the procedure.

Among the most common side effects for patients who’ve undergone a pneumonectomy are respiratory issues. To combat shortness of breath following a pneumonectomy, a patient may be required to do breathing exercises with a spirometer to help train their remaining lung to function properly.

In general, the major cause of mortality following thoracic surgery, including pneumonectomy, is respiratory issues. Between 15 – 20% of thoracic surgery patients experience these complications, including atelectasis (collapsed lung), pneumonia or respiratory failure. The odds of pneumonectomy risks can be reduced when the procedure is performed in cancer centers by experienced mesothelioma specialists.

Risks Associated with Pneumonectomy
  • Abnormal heart rhythms
  • Complications from anesthesia
  • Internal bleeding
  • Pneumonia
  • Pulmonary embolism (blood clot in the lung)
  • Reduced blood flow to the heart
  • Respiratory failure
  • Shock

Risks following pneumonectomy can be substantial. Malignant mesothelioma patients and their loved ones should be aware of potential complications and all treatment options available to them when making treatment decisions. Patients should discuss all options with their healthcare team and determine what treatment they feel most comfortable with.

Author: Linda Molinari

Editor in Chief, Mesothelioma Cancer Alliance

Linda Molinari

Reviewer: Annette Charlevois

Patient Support Coordinator

Annette Charlevois
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Sources

Cancer Treatment Centers of America. Pneumonectomy. Treatments.

Darling G, Abdurahman A, et al. Risk of a Right Pneumonectomy: Role of Bronchopleural Fistula. Annals of Thoracic Surgery. February 2005;79(2):433-7. doi: 10.1016/j.athoracsur.2004.07.009

Johns Hopkins Medicine. Pneumonectomy. Health Library.

Matsutani N, Okumura S, et al. Pneumonectomy in pulmonary metastasis. Journal of Thoracic Disease. November 2017; 9(11): 4523–4530. doi: 10.21037/jtd.2017.10.109

Pricopi C, Mordant P, et al. Postoperative morbidity and mortality after pneumonectomy: a 30-year experience of 2064 consecutive patients. Interactive CardioVascular and Thoracic Surgery. March 2015; 20(3): 316–321. doi: 10.1093/icvts/ivu417

Sengupta S. Post-operative pulmonary complications after thoracotomy. Indian Journal of Anaesthesia. September 2015; 59(9): 618–626. doi: 10.4103/0019-5049.165852

Vannucci F, Vieira A, et al. The technique of VATS right pneumonectomy. Journal of Visualized Surgery. January 2018; 4:11. doi: 10.21037/jovs.2017.12.01

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