What Is an Extrapleural Pneumonectomy?

The extrapleural pneumonectomy, or EPP, is performed on patients in the early stages of pleural mesothelioma. This is when the cancer is only within the chest cavity.

This treatment 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, [the EPP] 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

Benefits of an Extrapleural Pneumonectomy

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, patients underwent a combination of EPP and intensity-modulated radiation therapy (IMRT). They 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.

A 2022 study concluded that, in a multimodality treatment setting, EPP was comparable to pleurectomy and decortication for long-term outcomes. However, EPP had higher mortality rates following surgery. The study suggested that patients undergo the safest option they can tolerate.

Surgical Consultation for EPP

The benefits and risks of an EPP will be thoroughly discussed during a consultation with the surgeon and the surgical team.

The consultation serves as an opportunity for you and the surgical team to talk about your questions and concerns, and it can be done in person or virtually. They will review your medical records, imaging scans and biopsy test results, and discuss details of the procedure, including recovery.

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Risks and Drawbacks

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 to the less-radical P/D procedure.

In the study of 255 pleural mesothelioma patients, EPP had a postoperative mortality (death within 30 days) of 10.5%, compared to just 3.1% with P/D.

The morbidity (complication) rate of EPP was 24.2%, while P/D was just 3.8%. Nearly 10% of EPP patients had an unexpected return to the operating room compared to just 1.5% of P/D patients.

Another risk patients may face 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% of pleural mesothelioma patients. Although the local recurrence rate drops to 13% with post-surgery radiation therapy, recurrence at distant sites was a problem in up to 55% of patients.

Extrapleural pneumonectomy has several short-term risks, including:

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

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.

Quick Fact:
Extrapleural pneumonectomy offers a median overall survival of 12 to 22 months, compared with 13 to 29 months with P/D.

About the Procedure

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 PET/CT scan, make sure the cancer has not spread beyond the lungs.

Extrapleural pneumonectomy is performed under general anesthesia. The surgeon makes an incision, approximately 9 to 10 inches long, on the side. Once the incision is made, the doctor will remove the sixth rib and use a rib spreader to 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.

External beam radiation therapy for pleural mesothelioma
Extrapleural pneumonectomy surgery is used to treat pleural mesothelioma in early stages.

What to Expect After Surgery

Recovery from an EPP can be very slow. Rarely, patients will need to breathe with the assistance of a respirator for the first few days after the operation, and the drainage tubes will remain in place for one to two days to monitor for bleeding and air leak.

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 walk and take deep breaths, giving the remaining lung the best chance to take over all lung functions.

Even six months after the procedure, patients may find that exercise is difficult because of shortness of breath.

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