Extrapleural Pneumonectomy

Patient Advocate Karen Selby describes an extrapleural pneumonectomy (EPP).

An extrapleural pneumonectomy (EPP) involves the removal of a cancerous lung as well as parts of the chest lining, heart lining, nearby lymph nodes and diaphragm. The surgery, which is quite serious, is used almost exclusively in the treatment of malignant pleural mesothelioma. Not all patients are eligible for EPP surgery, which can help control tumor growth.

EPP is performed on patients in the early stages of mesothelioma, when the cancer has not yet spread to the lymph nodes or surrounding organs. This allows for the maximum amount of cancerous tissue to be removed. Because mesothelioma is usually not diagnosed until it reaches Stage III or IV, many patients are not candidates for this surgery.

Extrapleural pneumonectomy can also help ease breathing and improve quality of life. After recovery, patients will feel more comfortable, allowing them to return to their daily tasks or even go back to work.

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Benefits

Because EPP removes most of the cancerous tissue, the procedure can increase the life span of a mesothelioma patient. When combined with regimens of chemotherapy or radiation, it can increase a patient's life span by months or, in some cases, years.

The procedure is potentially curative and may be the most effective way to control mesothelioma. It can slow the cancer's progression while helping with breathing, which significantly improves quality of life. By performing high-dose radiation therapy after the procedure, doctors often can prevent the cancer from returning locally.

Some doctors argue that compared with other surgeries, EPP more frequently allows surgeons to completely remove all visible signs of cancer.

While extrapleural pneumonectomy was once a standard surgery for pleural mesothelioma, many physicians prefer pleurectomy/decortication (P/D), a less radical procedure. The latest comparative studies suggest pleurectomy/decortication has lower rates of death and morbidity (complications other than death) after surgery, but the rates for EPP have been improving over time. Extrapleural pneumonectomy offers a median overall survival of 12 to 22 months, compared with 13 to 29 months with P/D.

Risks

Surgery Icon

The most serious risk of EPP surgery is death during or shortly after the procedure. In one 2013 review of seven studies comparing the results of extrapleural pneumonectomy and pleurectomy/decortication, the death rate for EPP was 6.8 percent, compared with 2.9 percent with P/D.Doctors have long debated which surgery is best for patients.

Another major problem after EPP is cancer recurrence. A 2012 manuscript on multimodality therapy for mesothelioma states that after EPP, the cancer returns locally in up to 80 percent of pleural mesothelioma patients. Although the local recurrence rate drops to 13 percent with post-surgery radiation therapy, recurrence at distant sites was a problem in up to 55 percent of patients.

As for long-term risks, some patients may suffer from shortness of breath. This problem could mean dependence on an oxygen tank or mechanical respirator for months, perhaps years, after surgery.

Extrapleural pneumonectomy also has several short-term risks, including:

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

Signs of serious problems that may occur after EPP include fever, chest pain, cough and shortness of breath. An incision that becomes red, swollen, painful or starts to ooze blood after surgery is another warning sign. If you experience any of these problems, you should contact your doctor immediately.

About the Procedure

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Extrapleural pneumonectomy was first used in the 1940s to treat tuberculosis. During the early years of its use, the surgery resulted in a high mortality rate. Improvements have significantly improved the survival rate.

Before the surgery, doctors perform tests to make sure the remaining lung will be strong enough to function on its own. Doctors also test the patient's heart to ensure he or she is healthy enough to undergo major surgery. Other tests, including a bone scan and CT scan of the abdomen and head, make sure that the cancer has not spread beyond the lungs.

An extrapleural pneumonectomy is performed under general anesthesia. The surgeon makes an incision, approximately 9 to 10 inches long, either in the front of the body or on the side. Once the incision is made, the doctor will inspect for diseased tissue and remove as much cancerous tissue as possible. This will include the entire cancerous lung, as well as parts of the pericardium, diaphragm, and parietal pleura, as well as close lymph nodes.

Regions of the Chest Affected by Extrapleural Pneumonectomy

Extrapleural Pneumonectomy - Diagram of Chest

What to Expect After Surgery

Recovery from an EPP can be very slow. Respirators are used for the first few days to help patients breathe, and drainage tubes minimize the buildup of fluid. Patients generally stay in the hospital for at least two weeks after surgery. They are monitored closely, since complications are not unusual with this procedure.

The total recovery period is at least six to eight weeks, but is often longer. Patients generally are advised to take their recoveries slowly and get plenty of rest in the months following the procedure. The remaining lung must be given ample time to take over all lung functions. Even six months after the procedure, patients may find that exercise is difficult because of shortness of breath.

Learn More on How to Reach Out for Support During Recovery

Additional Resources

  1. Shrager, J., Sterman, D. and Kaiser, L. (2002). Surgery and Staging of Malignant Mesothelioma. London: Martin Dunitz.
  2. Tannapfel, A. (2011). Malignant Mesothelioma. Germany: Springer-Verlag Berlin Heidelberg.
  3. University of California San Francisco. (n.d.). Extrapleural Pneumonectomy. Retrieved from http://thoracic.surgery.ucsf.edu/conditions--procedures/extrapleural-pneumonectomy-.aspx
  4. Cao, C. et al. (2013, December 19). A Systematic Review and Meta-analysis of Surgical Treatments for Malignant Pleural Mesothelioma. Lung Cancer. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24360321
  5. Flores, RM et al. (2008, March). Extrapleural Pneumonectomy Versus Pleurectomy/Decortication in the Surgical Management of Malignant Pleural Mesothelioma. The Journal of Thoracic and Cardiovascular Surgery. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18329481
  6. Zauderer, M. and Krug, L. (2012, June 1). The Evolution of Multimodality Therapy for Malignant Pleural Mesothelioma. Current Treatment Options in Oncology. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3321839/

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