An extrapleural pneumonectomy (EPP) for pleural mesothelioma 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 can help control tumor growth, is a more radical procedure than the lung-sparing pleurectomy/decortication procedure offered to patients with earlier stage mesothelioma.
EPP is performed on patients in the early stages of pleural mesothelioma, when the cancer is confined to the chest cavity. This allows for the maximum amount of cancerous tissue to be removed. Because mesothelioma is usually not diagnosed until it reaches stage 3 or 4, many patients are not candidates for this surgery.
An EPP 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.
Some doctors argue that compared with other surgeries, EPP more frequently allows surgeons to completely remove all visible signs of cancer. However, many mesothelioma specialists and researchers believe the aggressive surgery is dated and too risky given advancements with the lung-sparing pleurectomy/decortication (P/D).
“It all depends on the patient selection. In the right patient population, it can be done safely and effectively and provide survival hope. The key is selecting the right patients.”
— Dr. Sameer Jhavar, radiation oncologist at Baylor Scott & White Medical Center
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.
In a 2017 study at the Baylor Scott & White Medical Center in Temple, Texas, patients who underwent a combination of EPP and intensity modulated radiation therapy (IMRT) had a median survival of 38.2 months and a median relapse-free survival of 24.4 months.
Although there is no curative surgery for mesothelioma, the procedure has long been an effective way to control the asbestos-related cancer for select patients. 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.
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The most serious risk of EPP surgery is death during or shortly after the procedure. A three-year, multicenter study published in 2014 showed the mortality rate for EPP is significantly higher compared tothe less-radical P/D procedure.
Extrapleural pneumonectomy offers a median overall survival of 12 to 22 months, compared with 13 to 29 months with P/D.
In the study of 255 pleural mesothelioma patients, EPP had a postoperative mortality (death within 30 days) of 10.5 percent, compared to just 3.1 percent with P/D.
The morbidity (complication) rate of EPP was 24.2 percent, while P/D was just 3.8 percent. Nearly 10 percent of EPP patients had an unexpected return to the operating room compared to just 1.5 percent of P/D 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 postsurgery radiation therapy, recurrence at distant sites was a problem in up to 55 percent of patients.
Extrapleural pneumonectomy has several short-term risks, including:
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.
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.
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 increased 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 they are healthy enough to undergo major surgery.
Other tests, including a bone scan and CT scan of the abdomen and head, make sure 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, parts of the heart lining (pericardium), diaphragm, lining of the lung (pleura) as well as nearby lymph nodes.
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, giving the remaining lung 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.
Karen Selby joined Asbestos.com in 2009. She is a registered nurse with a background in oncology and thoracic surgery and was the director of a tissue bank before becoming a Patient Advocate at The Mesothelioma Center. Karen has assisted surgeons with thoracic surgeries such as lung resections, lung transplants, pneumonectomies, pleurectomies and wedge resections. She is also a member of the Academy of Oncology Nurse & Patient Navigators.
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