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

Mesothelioma patients with the epithelioid cell type typically have a more favorable response to aggressive surgery because these cells spread more slowly and stick together more readily. In contrast, the sarcomatoid cell type is less likely to benefit from EPP because of its rapid spread and poor prognosis. For biphasic mesothelioma tumors (which contain both epithelioid and sarcomatoid cells), eligibility often depends on the proportion of epithelioid cells present.

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 (one lung is unable to expand fully) and recurrent pleural effusions (extra fluid between the lungs and chest wall).

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: The diaphragm and pericardium are rebuilt using durable synthetic materials, such as GORE-TEX and GORE PRECLUDE membranes, respectively. Surgeons anchor these patches with permanent sutures to the chest wall or residual rim to maintain structure and prevent herniation.
5. Closure: Your surgeon will close the incision and you’ll move to recovery. You’ll also be closely monitored with supportive care.

During an EPP, the anesthesiology team plays a critical role in managing the single remaining lung. They use a special tube to keep the target lung deflated while the other lung continues to function. From the moment surgery begins, the anesthesiologist closely monitors oxygen levels, uses gentle ventilation settings to protect the remaining lung, manages shifts in chest structure and fluid levels, and stands ready to act if oxygen levels drop or blood pressure falls.

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.”

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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 (cancer returning at or near the same area) 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

Reconstruction of the diaphragm and pericardium carries an increased risk of incisional hernias. These hernias occur when abdominal organs protrude into the chest cavity, often resulting from a diaphragm that has not been properly secured.

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. They may signal life-threatening complications. A fever might indicate a developing empyema (pus buildup behind the patch used in reconstruction) and a cough could point to a bronchopleural fistula, where the airway leaks into the chest cavity. If you notice any of these symptoms or if your incision becomes red, swollen, painful or begins to ooze blood, 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.

After an EPP, the body undergoes significant change as it adapts to having one lung removed. The remaining lung expands to take up more room; the heart and central chest area shift slightly toward the side where the operation was performed; and fluid slowly fills the empty space in the chest.

It’s common for patients to have a harder time taking deep breaths and get tired more quickly. Many people can get back to their everyday daily lives after undergoing breathing exercises, physical therapy and paying close attention to potential issues like the shift of the chest organs or fluid buildup in the lungs.

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.”

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Michael Cole: My Reaction to Learning About an Extrapleural Pneumonectomy

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I really didn’t worry that much about the surgery itself.

I was more concerned about getting rid of the cancer.

And I’m not sure that I was really prepared for how difficult that surgery was.

Even though the doctor told me that it was as big as any surgery that a person could possibly have.

But I was willing to accept that. Let’s just get it done was my attitude.

I think that is the right attitude to have about it, but the surgery, it was difficult.

There’s no doubt about it. It was difficult to recover from, but it was not insurmountable.

Doctor Sugarbaker told me after a period of time, he said, I’m so glad that you’re doing as well as you are. He said, so many of my patients just lay there and die. And he said, there’s no medical reason for it.

They just die.

And I think I understand perhaps why.

It would have been so easy to just give up, to just lay there and stop breathing.

In my case, I just kept going.

I did not quit.

And, I think that one needs to keep in mind that if I can get through this next minute, this next hour, this next day, it will get better.

And it did.

Each day, I would get a little better and a little better.

And, over a period of days, weeks, months, I continued to get better to the point where I would look back and, you know, after a month, two, three, and say, wow.

I can’t believe. Just seems like just the other day, I was only able to walk ten steps, thirty steps, a hundred steps. Now, you know, I walk in a quarter of a mile, half a mile. I can walk a mile.

But, there was a point when I could not even imagine that.

Now, I can’t walk as far as, you know, someone who’s in reasonably good shape and, you know, all of this. But I can walk around as much as a lot of people, and I have to stop, you know, and, catch my breath and, you know, more often than the average person probably.

But I can still get around and do most of the things most other people my age do.

And so it’s, it’s amazing now to look back and think how far I’ve come.

And I think that people need to to know that it’s possible.

As bad as you may feel, as little as you were able to do, it will get better. If you just keep plodding along, keep going as far as you can go each day, keep pushing yourself, but don’t push too far.

And that’s something I was told over and over and over again. Nobody knows, except you, how far you can go.

And so, you know, push yourself as far as you can go, not too far. What happens when you go too far?

Takes you a couple of days to kinda get back to where you were. You can easily wear yourself out so you’re not, you know, able to do much for two or three days.

And you can easily over exert yourself lifting things like this. Don’t do too much of that. You’ll regret it. You’ll learn real quick not to do it. Do what you can do and and try to do a little more than you did yesterday.

If something happens and you fall back, you know, for some reason, you get sick again, have another hospital stay, whatever happens, it’s gonna set you back.

And that’s really frustrating.

That’s hard to deal with sometimes, you know, because you feel like you work so hard to get up to a point, and then you get set back. But just you don’t think about that. You just start where you’re at, and start working your way back up again. And I’m a firm believer, really, that most people live about as long as they want to.

And, as long as you don’t give up, you’re likely to keep moving ahead.

It’s, you know, when you decide it’s not worth it anymore, that’s probably when, you know, when you’re gonna stop getting better.

And I don’t mean to put a lot of pressure on somebody or give the idea that, oh, somebody just died because they quit or whatever. It’s not really true, but you’re not going to continue to get better unless you want to continue to get better.

And so a lot of it does come down to the attitude.

Also, there are some people that are at a point in life when, you know, they decide that because of age, condition, whatever, that it’s not worth it, and that’s okay too.

Everybody has to make a decision about what it’s worth to them to do that treatment, to go through this surgery, to you know. And for everybody, that’s going to be different.

And I think what’s coming to mind, the reason I say this is, their loved ones need to respect that too.

Because, you know, there are times I can completely understand that there are circumstances where a person may say, you know what? I’m not going to do that. It’s not worth it to me. And that can be a perfectly rational decision.

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.

Six Week EPP Recovery Process

In the first six weeks following an EPP, a respiratory therapist helps rebuild breathing strength and lung function using a structured rehabilitation program. This program uses breathing tools, walking, deep-breathing exercises and regular check-ins with the respiratory therapist. Before attempting these steps on your own, talk to your doctor. 

Weeks 1-2:

• Use a breathing tool like an incentive spirometer every hour while awake (10 deep breaths each time).
• Begin assisted walking: 5–10 minutes every 2-3 hours, as pain and chest tubes allow.
• Focus on deep breathing and coughing exercises to clear secretions.

Weeks 3-4:

• Try walking for 15–20 minutes twice a day.
• Climb one flight of stairs if allowed by your doctor.
• Try to hit about half of what your therapist measured for your pre-surgery forced vital capacity.

Weeks 5-6:

• Increase walking to 20–30 minutes, aiming for two sessions per day.
• Climb two flights of stairs, gradually.
• Introduce breathing muscle exercises or resistance breathing (with therapist guidance).
• Regular check-in with respiratory therapist: monitor oxygen saturation, respiratory rate, and perform a 6-minute-walk test if available.

This process is a general guideline and should be tailored by your medical and rehab team based on your specific situation. Staying consistent with breathing exercises, mobility and therapy will help you make meaningful progress during this recovery period.

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.

In our survey of mesothelioma surgeons, nearly 67% reported extrapleural pneumonectomy as yielding the best overall outcomes for eligible pleural mesothelioma patients, while 33% favored pleurectomy/decortication (P/D). Both surgeries can play an important role depending on the patient’s stage of cancer, overall health and surgical goals. These findings reflect how expert perspectives differ when tailoring treatment plans for individual patients.

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 typically covers major charges like the surgeon’s fee, hospital stay (including ICU care), anesthesia services, synthetic materials (for diaphragm and pericardium reconstruction), and initial chemotherapy. 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.

It does not account for many out-of-pocket expenses such as long-term physical therapy or pulmonary rehab, travel and lodging for treatment, home health care, nutritional supplements or lost income.

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 rehabilitation is available for EPP patients?

After surgery, EPP patients get follow-up care, physical therapy and pain management. Pain relief starts in the operating room with pain medications given through a thoracic epidural catheter or another method. Over the next couple of days, pain meds are given via IV before switching to oral medications. From there, rehabilitation continues with physical and respiratory therapy, guidance from a dietitian on nutrition for recovery, and access to financial assistance programs to help cover treatment-related costs.

Are there nonsurgical 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.