Extrapleural Pneumonectomy

What Is an Extrapleural Pneumonectomy?

An extrapleural pneumonectomy is a surgical procedure for pleural mesothelioma that removes the entire cancerous lung. An EPP can improve your breathing and quality of life. After recovery, people often feel more at ease. This can allow you to return to you daily activities or even resume work.

This mesothelioma procedure gets its name from the original surgery known as a pneumonectomy, which removes only the affected lung. The “extrapleural” means the surgeon goes beyond the entire removal of your lung to include the removal of its pleural lining, nearby lymph nodes and parts of the heart lining and diaphragm.

Key Facts About Extrapleural Pneumonectomy

1. Extrapleural pneumonectomy is a complex, invasive surgery that removes one diseased lung and other structures in your chest to treat pleural mesothelioma.
2. EPP is for early-stage cancer confined to one side of the chest. You must be in good overall health to tolerate the procedure.
3. Recovery from EPP is lengthy and requires significant physical rehabilitation. Fatigue, breathlessness and pain are common after the surgery.
4. While it offers a chance for improved survival, EPP can lead to serious complications. Careful patient selection limits the risk of complications.

Dr. Sameer Jhavar, a radiation oncologist at Baylor Scott & White Medical Center, believes an EPP can help certain patients. Dr. Jhavar says, “It all depends on the patient selection. In the right patient population, [EPP] can be done safely and effectively and provide survival hope.” 

Who Is Eligible for EPP?

You may be eligible for EPP for mesothelioma if your doctor believes you can recover from possible complications. You should also be in good overall health. Eligibility is limited if you have the sarcomatoid cell type, late-stage cancer or certain preexisting conditions. Talk with a mesothelioma surgeon to determine if EPP could benefit you.

EPP Eligibility Criteria

• Absence of certain preexisting conditions
• Diagnosis with early-stage pleural mesothelioma between stages 1 and 3
• Epithelial or biphasic cell type
• Good function of the unaffected lung (known as pulmonary reserve)
• Good overall health and adequate heart and kidney function

The National Comprehensive Cancer Network doesn’t recommend surgery for those whose pleural mesothelioma has progressed beyond stage 3A. Unfortunately, many people are diagnosed after their cancer has progressed to stages 3B or 4. 

Surgeons may recommend pleurectomy/decortication for certain people who can’t tolerate the more aggressive EPP surgery. A P/D may be better for people with symptoms like entrapped lung syndrome and recurrent pleural effusions.

How Is Extrapleural Pneumonectomy Performed?

Before performing EPP, your mesothelioma doctors will test your lung function to ensure your remaining lung will be strong enough to work well on its own. Your doctor will also check your heart health.

EPP Procedure Steps

1. Preparation: You’ll receive general anesthesia to ensure comfort during surgery.
2. Incision: Your surgeon makes a careful incision on one side of your chest to access the affected area. Your doctor will then remove your sixth rib and use a rib spreader to look for any diseased tissue.
3. Tissue Removal: The diseased lung, pleura, nearby lymph nodes and parts of your diaphragm and pericardium are carefully removed. Your surgeon may remove ribs or parts of your peritoneum if they see cancer elsewhere.  They aim to remove as much cancerous tissue as possible.
4. Reconstruction: Your diaphragm and pericardium are rebuilt with synthetic materials.
5. Closure: Your surgeon will close the incision and you’ll move to recovery. You’ll also be closely monitored with supportive care.

Imaging scans let your surgeon see how far the cancer has spread to guide surgical decisions. A PET/CT scan can assess if tumors have spread to the other side of your chest or into your abdomen. An MRI can identify tumors in your chest wall and diaphragm.

What Are the Benefits of Extrapleural Pneumonectomy?

An extrapleural pneumonectomy can extend survival, reduce symptoms and improve your quality of life. While there is currently no cure for mesothelioma, EPP can help control it. Many people feel better after surgery, with extended survival, and some live for many years.

Benefits of Extrapleural Pneumonectomy 

• Disease Control: An EPP removes your affected lung and nearby tissues to eliminate cancer. It removes a lot of cancerous tissue at once, which helps slow disease progression.
• Improved Survival: The procedure can extend life expectancy, especially in early-stage cases. In people with stages 2 to 3A mesothelioma, EPP can remove more cancer tissue than P/D, which is important in improving the odds of survival.
• Multimodal Therapy: EPP enhances how additional treatments like chemo or radiation work. These can extend lifespan. Using high-dose radiation therapy after EPP, doctors can help prevent the cancer from coming back in the same area.
• Symptom Relief: EPP has the potential to reduce pain, breathlessness and other cancer-related symptoms.

Pleural mesothelioma survivor Michael Cole sought medical advice from mesothelioma pioneer Dr. David Sugarbaker, who worked at Baylor College of Medicine in Houston, in 2015. Sugarbaker recommended an aggressive treatment with EPP and chemo.

“As it has turned out, the EPP with HITHOC followed by four rounds of chemotherapy was not the end of my treatment journey, but rather only the beginning,” Cole tells us. “I believe the aggressive treatment I had in the beginning was absolutely necessary to give me a chance to be here now, and I am grateful for the decision we made.”

Risks and Drawbacks of EPP

Some mesothelioma surgeons believe the lung-sparing pleurectomy and decortication is a safer alternative to EPP. In fact, most surgeons avoid this aggressive procedure. A P/D is ideal for stage 1 pleural mesothelioma, while an EPP can remove visible tumors in patients with stages 2 through 3A. Some surgeons can offer P/D surgery and convert the procedure into an EPP if they discover more cancer than imaging detected.

EPP can offer hope, but the most serious risk is death after surgery. The mortality rate for EPP is higher compared to the less invasive P/D procedure. A 2024 review comparing mortality found a death rate of 6% for EPP and 2.2% for P/D.

Complications can arise after EPP surgery. The 2024 review reported the complication rate ranged between 38% and 68% for EPP. The P/D complication rate ranged between 26% and 58%. Notably, nearly 10% of EPP patients required an unexpected return to the operating room, compared to just 1.5% for P/D patients.

Additionally, according to a 2012 study on multimodal therapy for mesothelioma, local recurrence can occur in up to 80% of EPP patients. This rate drops to 13% when patients receive radiation therapy after surgery. But recurrence at distant sites can affect up to 55% of patients.

Short-Term EPP Risks

Other risks of EPP for mesothelioma include blood clots, heart problems and pneumonia. Long-term risks can include shortness of breath. This might lead to needing an oxygen tank or a mechanical respirator for a while after surgery.

Common Short-Term EPP Risks

• Abnormal connection between the bronchial cut and pleural space
• Blood clot in the lungs
• Fluid accumulation in lungs
• Heart problems (cardiac arrhythmias and heart attack)
• Kidney failure
• Pneumonia
• Pus accumulation in pleural space
• Wound infection

It’s important to watch for signs of serious issues that may develop after an EPP. These signs include fever, chest pain, cough and shortness of breath. If your incision becomes red, swollen, painful or starts to ooze blood, these could also be warning signs. If you notice any of these symptoms, please contact your doctor immediately. 

What Is the Recovery Process Like After EPP?

Recovering from an EPP can take some time. Healing happens in phases. It also gets easier with time when you follow the guidance of your medical team. 

1. Immediate Postsurgery: In some cases, people need a respirator for the first few days after surgery. Drainage tubes will be in place for 1 to 2 days to monitor for any bleeding or air leaks. Most people stay in the hospital for at least 2 weeks for monitoring.
2. First 6-8 Weeks: The recovery period lasts at least 6 to 8 weeks, but can extend longer for some people. It’s important to start moving and taking deep breaths to maintain good lung function.
3. Long-Term Recovery: Even 6 months after surgery, you might notice that exercise can still feel challenging because of shortness of breath. Remember, this is all part of the healing journey, and in time, you will likely feel stronger.

Michael Cole tells us recovery from his EPP was challenging. But he credits the surgery with his long-term survival.

He shares, “When I woke up, I felt like I had been run over by a truck, and I’m pretty sure I looked worse. My whole body was out of whack, including my remaining lung, It hasn’t been easy, and we have been through hard times and uncertainty since that day, but don’t misunderstand. We have not been in despair.”

Prognosis After Surgery

The prognosis after EPP depends on your age, overall health, cancer stage, cell type and whether your surgeon was able to remove all tumors. Lymph node involvement is one of the most important factors. More cancer in the lymph nodes lowers the success rate of EPP.

A 2024 review of EPP for pleural mesothelioma reported a median survival of 18 months. The longest survival reached 35 months. But there are some patients who live longer. For example, Michael Cole’s EPP surgery was 10 years ago.

Additional therapies can improve prognosis after EPP. The National Comprehensive Cancer Network advises chemo before surgery based on clinical trial evidence. Postoperative chemo is also recommended for those who didn’t receive chemo before surgery. Combining treatments provides the best chance for improved survival.

Michael Cole

Verified Asbestos.com Survivor

10-Year Pleural Survivor Undergoes Aggressive EPP Surgery

Michael Cole describes how aggressive EPP treatment for mesothelioma saved his life. He also explains his personal cancer journey and his other mesothelioma treatments.

Michael Cole

Verified Asbestos.com Survivor

Read Michael’s story

How Does Extrapleural Pneumonectomy Compare to Other Treatments?

Within the mesothelioma medical community, opinions vary about the value of EPP compared to other surgeries. Some experts believe EPP helps certain patients, while others think P/D is safer and just as effective.

A 2022 study found EPP and P/D had similar long-term outcomes when used as part of a larger treatment plan. However, EPP showed higher rates of mortality after surgery. The study recommends patients choose the safest treatment they can handle.

The National Comprehensive Cancer Network says cell type, cancer stage, overall health and how much surgical risk a patient can accept should guide whether a patient receives EPP or P/D. A patient’s lung function and the surgeon’s skill and experience are also important considerations.

Common Questions About Extrapleural Pneumonectomy

How much does extrapleural pneumonectomy cost?

The potential cost of an extrapleural pneumonectomy is around $82,000. This estimate can vary greatly throughout the U.S. It’s based on a 2019 report about the cost of mesothelioma treatment, and it accounts for inflation.

How can patients prepare mentally and physically for EPP?

EPP patients can prepare for the procedure by improving their overall health. A balanced diet, gentle exercise and good sleep prepare the body for aggressive surgery. Preoperative pulmonary rehabilitation may be recommended. Quitting smoking will improve the function of the remaining lung after the procedure. Mental preparation may include counseling, joining support groups and learning about the procedure and recovery process.

What kind of support resources are available for EPP patients?

EPP patients can benefit from postsurgical follow-up care, physical therapy and pain management programs. A dietitian can recommend a diet plan to optimize recovery and maintain strength. Medical grants and other forms of financial assistance can help patients afford treatment.

Are there non-surgical alternatives to EPP for mesothelioma?

Other treatments for mesothelioma include immunotherapy, chemotherapy and radiation. Oncologists also use targeted therapies and Tumor Treating Fields therapy to treat mesothelioma.

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