Extrapleural Pneumonectomy

An extrapleural pneumonectomy (EPP) treats malignant pleural mesothelioma by removing the cancerous lung, part of the parietal pleura (chest lining), pericardium (heart lining), and diaphragm. The operation aims to control tumor growth but is one of the most aggressive procedures for pleural mesothelioma.

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What Is a Mesothelioma Extrapleural Pneumonectomy?

A mesothelioma extrapleural pneumonectomy (EPP) is a type of mesothelioma surgery used for those in the early stages of pleural mesothelioma.

EPP is an invasive surgery that involves:

  • Opening the chest cavity either through the front (a sternotomy) or on the side (a thoracotomy) and making a 9-inch incision
  • Removing all visual signs of cancer including the entire diseased lung as well as cancerous tissue on the pleural lining of the chest, heart, and diaphragm
  • Chemotherapy and sometimes radiation therapy before and after surgery for best results.

Because the surgery is so radical, candidates must be in overall good health with strong heart function and a remaining healthy and functioning lung.

While extrapleural pneumonectomy is considered curative in that it seeks to remove all present pleural mesothelioma and extend a person’s life, it poses significant risks such as internal bleeding, respiratory failure, and even death.

Extrapleural pneumonectomy differs from another similar surgery, pleurectomy/decortication (P/D), in that P/D spares the lung and only removes the membrane surrounding the lungs.

According to a medical review published in the journal Lung Cancer, the median survival rate of patients who had an EPP was 12-22 months compared to 13-29 months for P/D.

The medical community is still debating which is preferable since the extrapleural pneumonectomy may remove more cancer, but poses a much higher risk than the less invasive P/D.

Quick Facts About Extrapleural Pneumonectomy

  • The first EPP was performed on a mesothelioma patient in 1976.
  • Extrapleural pneumonectomies are always performed with chemotherapy and sometimes radiation before, during, or after surgery.
  • According to the American Cancer Society (ACS), about 1 in 3 patients who have an EPP may experience major complications.
  • Extrapleural pneumonectomy is a potentially curative surgery and has offered some people long periods without cancer, according to the ACS.

The Extrapleural Pneumonectomy Procedure

Extrapleural pneumonectomy is a complex procedure. Only pleural mesothelioma patients who are physically fit enough to withstand surgical complications and recovery can undergo an EPP.

Here is what occurs during this procedure:

  1. General Anesthesia: The patient is given a general anesthetic before the procedure begins. It is also common for patients to have received chemotherapy or radiation therapy in the weeks preceding the surgery.
  2. Open Surgery: The surgeon opens up the patient’s chest cavity over the sixth rib and visually inspects the lining. In some cases, the sixth rib is removed to widen the cavity.
  3. Lung and Tissue Removal: Surgeons will then remove the diseased lung and other areas of concern, including the pleural lining of the heart, chest, and diaphragm. Great care is taken not to enter the pleural cavity, as this could cause cancer cells to get spread to other areas. The chest cavity is then sprayed with a thrombin solution to help treat any bleeding.
  4. Recovery: Patients often require a prolonged hospital stay to recover as the procedure increases the load on the heart and the remaining lung. During this time the patient will be closely monitored by medical staff. After discharge, there is an additional recovery period of six to eight weeks while the body adjusts.

Extrapleural pneumonectomy is not for every mesothelioma patient. Only those in the early stages who are otherwise in good health are candidates for this radical surgery. For these patients, extrapleural pneumonectomy can improve their length and quality of life.

Extrapleural Pneumonectomy Risks and Side Effects

Surgical treatment for mesothelioma remains contested among mesothelioma doctors. While EPP has been the standard method for over 30 years to extend life for those with an early mesothelioma diagnosis, it poses many deadly risks for even the most ideal candidate.

One-third of the patients who receive an EPP experience major complications.

EPP complications may include:

  • Bleeding
  • Blood clots
  • Changes in heart rhythm
  • Chest fluid build-up
  • Loss of lung function
  • Pneumonia
  • Wound infections
  • Death

Still, the University of California, San Francisco, Thoracic Surgery Department says extrapleural pneumonectomy is potentially the best procedure available to control malignant mesothelioma.

It delays the spread of the disease, improves breathing, and combined with radiation and chemotherapy it can lengthen life expectancy.

Yet, 6% of patients who undergo this radical procedure die during or after the procedure from serious complications.

Additionally, extrapleural pneumonectomy can be associated with severe deterioration of cardiopulmonary function and quality of life.

Extrapleural Pneumonectomy vs Pleurectomy with Decortication

The newer procedure developed by Dr. Robert Cameron in the 1990s, pleural decortication, is less risky, but some mesothelioma doctors argue that it may also be less effective in removing the cancer.

P/D may be used either as a more invasive curative procedure or as palliative treatment.

The procedure involves the removal of:

  • The pleura lining the chest wall
  • The pleura coating the diseased lung
  • The pleura coating the mediastinum (space between the lungs) and the diaphragm

Unlike extrapleural pneumonectomy, pleural decortication may leave more residual tumor cells because the lung is left in place.

Did You Know?

According to the Lung Cancer medical review, the risk of death from complications during or after P/D is less than half that of extrapleural pneumonectomy: 2.9% vs 6.8%.

While the mortality risk for P/D is lower than it is for EPP, the long term survival rate for both surgeries was found to be similar, only slightly favoring P/D.

A Japanese study from the Hyogo College of Medicine found that 64% of patients who underwent P/D were acceptable candidates for chemotherapy when their cancer recurred, while only 25% of patients who had received an extrapleural pneumonectomy were able to receive chemotherapy when their cancer returned.

An analysis of several studies on both procedures showed an overall survival range of 13-29 months for P/D and 12-22 months for extrapleural pneumonectomy.

Because of the varying pros and cons of each procedure the medical community remains divided on which procedure is most effective. At this point, treatment is determined individually for each patient depending on the specifics of the case.

Who Is Eligible for an Extrapleural Pneumonectomy?

Not every person diagnosed with mesothelioma is a good candidate for an extrapleural pneumonectomy.

Patients with the following traits often make the best EPP candidates:

  • Early-stage, localized mesothelioma
  • Localized malignancy
  • No cancer in the lymph nodes or spread to other tissues
  • Overall good health
  • Strong heart and lung function

Because an extrapleural pneumonectomy involves removing a diseased lung, the remaining lung and the heart must be strong enough to bear the increased load.

Additionally, since this curative procedure seeks to remove all present cancer in the pleural area, if it has already spread to other areas of the body then only palliative care can be offered.

Extrapleural pneumonectomy is a technically complex operation usually performed at large mesothelioma cancer centers by thoracic surgeons with extensive experience treating and performing surgery on mesothelioma patients.

Extrapleural Pneumonectomy Recovery

Extrapleural pneumonectomy is an invasive and complex surgery with the potential for significant consequences.

6% of people who undergo this operation will not survive past 30 days due to severe complications. Yet, this means 94% of extrapleural pneumonectomy patients survive the operation.

Because of the severe trauma to the body, patients may experience complications.

Potential EPP complications include:

  • Infection
  • Lung fluid buildup
  • Pneumonia
  • Blood clots
  • Internal bleeding
  • Kidney failure
  • Heart problems
  • Pus in pleural space
  • Shortness of breath
  • Dependence on an oxygen tank or respirator

There is no question that extrapleural pneumonectomy is a very serious surgery fraught with possible complications. Still, not every patient will experience all the complications and may face only one or two.

Doctors agree that the most effective method for aiding recovery is taking steps to prepare ahead of time for the trauma the body is going to experience.

The renowned Cleveland Clinic offers instructions that may help aid recovery:

  • Improve diet: Eat a “cleaner diet” consisting of foods like fruits and vegetables that are rich in vitamins and minerals to reduce inflammation in the body and prepare for the upcoming shock of surgery. Dr. El Hayek says to avoid processed food, red meat and other foods that are difficult for the body to break down and cause inflammation.
  • Exercise: Get exercise even if it’s just taking a short walk or parking the car further away from the store in the parking lot. This will increase the chances of walking sooner after surgery. According to Dr. El Hayek, discharge from the hospital might depend on reaching a preoperative level of activity.
  • Avoid drugs: Stop smoking, drinking, or using any mood-altering substances that could affect sleep or anxiety level prior to surgery. Days leading up to the surgery cease any smoking or alcohol consumption which could affect anesthesia.
  • Visit the doctor: See your primary care physician to ensure all of your medications are optimally dosed. Your blood pressure and blood sugar need to be controlled for optimum surgical results. Higher blood sugar counts will inhibit wound healing, so the more they are controlled the better recovery you’ll have.

The mind and body connection is well known. Below, learn tips to prepare your mind for the trauma of undergoing a major surgery like extrapleural pneumonectomy.

Tips on preparing for surgery include: 

  • Learn as much as you can about EPP from reliable medical sources so you know exactly what is going to happen the day of the surgery.
  • Prepare a list of questions to ask your medical provider. According to anxiety specialist Dr. Zeev N. Kain, studies show that the more information a patient has the less anxiety will be experienced.
  • Speak to the anesthesiologist prior to the surgery about the plan for pain management after the surgery.
  • Dr. Kain recommends using guided imagery, breathing techniques, and music therapy prior to surgery and afterward to ease anxiety.
  • Most importantly, have a social support system in place to surround you during your recovery. Loving friends and family are crucial to you during this time.

For more information on mesothelioma surgeries and treatment options, contact our Justice Support Team and learn how we can help you navigate this difficult time.

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Mesothelioma Support Team
Reviewed by:Dr. Assuntina Sacco

Board-Certified Oncologist

  • Fact-Checked
  • Editor

Assuntina Sacco, MD is an Associate Professor of Internal Medicine at the University of California, San Diego (UCSD) Moores Cancer Center, where she also serves as the Medical Director of Infusion Services. She is a board-certified medical oncologist trained to treat all solid tumor types, with the use of chemotherapy, immunotherapy, targeted therapy, and clinical trials.

Dr. Assuntina Sacco is an independently paid medical reviewer.

Beth SwantekWritten by:

Contributing Author at the Mesothelioma Justice Center

Beth Swantek has been writing about the dangers of asbestos since 2013. Beth served as a media professional for over 30 years and began her career as a broadcast journalist. After her daughter suffered a traumatic brain injury at birth, Beth has devoted her life to helping men and women experiencing deep loss — such as those living with mesothelioma.

View 8 Sources
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    Accessed on February 09, 2018
  2. American Cancer Society. (n.d.) Surgery for Malignant Mesothelioma. Accessed on March 23, 2020. Retrieved from: https://www.cancer.org/cancer/malignant-mesothelioma/treating/surgery.html
  3. General Thoracic Cardiovascular Surgery. (2014, Mar. 19). Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma. Accessed on March 23, 2020. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153961/
  4. Journal of Thoracic Disease. (2019, Mar. 11) Extrapleural pneumonectomy. Accessed on March 23, 2020. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6462700/
  5. Cao, C., D. Tian, J. Park, J. Allan, K.A. Pataky, T.D. Yan, (2014, Feb.) A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma. Accessed on March 23, 2020. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/24360321
  6. University of California San Francisco Thoracic Surgery Department of Surgery. (n.d.) Extrapleural Pneumonectomy. Accessed on March 23, 2020. Retrieved from: https://thoracicsurgery.ucsf.edu/conditions-procedures/extrapleural-pneumonectomy.aspx
  7. Kain, Zeev N.(2017, Dec. 9). How to mentally prepare for surgery and recovery faster. Accessed on March 27, 2020. Retrieved from: https://www.psychologytoday.com/us/blog/the-anxiety-medicine/201712/how-mentally-prepare-surgery-and-recover-faster
  8. Cleveland Clinic Health Essentials. (2014, Apr. 14). Scheduled for surgery? Five ways to prepare yourself. Accessed on March 27, 2020. Retrieved from: https://health.clevelandclinic.org/scheduled-for-surgery-how-to-go-in-strong-ready/
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