Extrapleural Pneumonectomy

Summary

An Extrapleural Pneumonectomy (EPP) is used in the treatment of pleural mesothelioma and involves the removal of a cancerous lung. Part of the parietal pleura (chest lining), pericardium (heart lining) and diaphragm are also removed to complete the surgery. The operation aims to control tumor growth but is known as one of the most radical procedures for patients with pleural mesothelioma.

Extrapleural Pneumonectomy (EPP) Overview

If you have been diagnosed with pleural mesothelioma, it’s important to fully understand your treatment options.

If your specialist has recommended an extrapleural pneumonectomy, then here is what you need to know about this mesothelioma procedure:

  • EPP is a complicated procedure only performed on patients with early-stage localized mesothelioma, though it was first used to treat tuberculous empyema in 1949. Nowadays, it is almost exclusively performed for pleural mesothelioma.
  • Patients must be in overall good health with adequate lung and heart function to proceed with the surgery. If mesothelioma has spread to the lymph nodes or attacked surrounding tissue, then surgeons won’t likely recommend the procedure.
  • World-renowned surgeon, the late Dr. David Sugarbaker is credited with developing EPP surgery for pleural mesothelioma patients at Brigham and Women’s Hospital in Boston, MA.
  • The surgery is curative, but controlling the disease after the operation is a crucial concern. EPP is commonly performed in conjunction with radiation and chemotherapy.
  • Because of the demanding procedure, EPP is usually done in larger medical centers and performed by doctors who specialize in the surgery.
  • This kind of pleural mesothelioma surgery is controversial and complex. Risks include internal bleeding, respiratory failure, pneumonia, blood clotting, and death.
  • The median postoperative survival span is 38.2 months.

Extrapleural Pneumonectomy Procedure

An extrapleural pneumonectomy is a complex procedure. Only 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 Anesthetic: The patient is given a general anesthetic before the procedure begins. It is also common for patients to have received chemotherapy or radiation 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 disrupt the operative field with a spillage of malignant cells. The chest cavity is then sprayed with a thrombin solution to stop the bleeding and avoid a hemorrhage.
  4. Recovery: Patients often require a two-week stay in the hospital 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, and after discharge, there is an additional recovery period of six to eight weeks while the body adjusts.

Extrapleural Pneumonectomy Benefits

EPP has long been an efficient way to control mesothelioma, despite there being no actual cure to date. Because the entire lung is removed in the process, there is less risk of recurrence—when the mesothelioma comes back. Doctors agree that, compared with other surgeries to treat pleural mesothelioma, EPP allowed surgeons to remove all visible signs of cancer.

Combined with chemotherapy and/or radiation, the procedure can increase a patient’s lifespan with a median survival rate of 38.2 months, according to a 2017 study at Baylor Scott & White Medical Centre, Texas.

After surgery, the patient will be able to breathe more easily and enjoy an improved quality of life. Once the required six to eight weeks of recovery is complete, patients are generally be ready to go back to their daily tasks, and in many cases, return to work.

However, EPP is a very intricate procedure and is associated with many risks. Many mesothelioma specialists believe that the aggressive surgery is dated compared to other methods, and imposes increased dangers on patients.

EPP vs P/D

An alternative treatment to EPP is pleurectomy with decortication (P/D), preferred by renowned pleural mesothelioma specialist, Dr. Robert Cameron. P/D is a lung-sparing surgical procedure known as one of the most successful operations for pleural mesothelioma patients. It works by removing the lining of the affected lung while leaving the lung itself in place. This process claims to relieve the symptoms of the disease and extend the patient’s life. Much like EPP, a patient must be in the early stages of pleural mesothelioma and physically able to undergo the stress of surgery to be considered for P/D.

EPP Morbidity and Mortality Rates

EPP morbidity and mortality have decreased over the years due to improved patient selection and intraoperative care. The late Dr. David Sugarbaker, world-renowned doctor and certified thoracic surgeon, is widely credited for developing the first tri-modal treatment approach for pleural mesothelioma.

His method used a combination of EPP, intraoperative chemotherapy, and radiation to kill any remaining cancer cells after surgery. This technique has been proven successful to control pleural mesothelioma and keep symptoms at bay.

There are many debates among doctors as to the best treatment for pleural mesothelioma, with EPP and P/D at the heart of the discussion. Survival rates are relatively equal between both procedures, though EPP poses more risks to the patient and more potential side effects. However, while P/D saves the lung, it is not useful if the tumor has spread to the lung itself. In this case, EPP is required to thoroughly remove the lung and rid the patient of the entire tumor.

Who is Eligible for the Extrapleural Pneumonectomy?

Doctors consider many factors when choosing a suitable patient for the EPP procedure. The tumor location and size and mesothelioma subtype determine whether a patient should undergo surgery or not.

There are several staging systems in place to determine the classification of each case of pleural mesothelioma. The most recent staging system (the Brigham staging system) was created from analysis of over 180 patients at Dana-Farber Cancer Institute, Boston, Massachusetts.

Using the Brigham staging system, doctors look at tumor histology and nodal status, meaning that patients with nodal disease will not be considered as candidates for EPP. Patients must also be in generally good health—with a normal performance status and regular pulmonary functions—to be able to survive recovery.

Extrapleural Pneumonectomy Side Effects and Recovery

The complexity of the procedure means that there are many risks involved—the most serious being the mortality rate during or shortly after the procedure. Compared to the P/D method, EPP has a higher death rate within 30 days of the surgery. In a study of 255 pleural mesothelioma patients, EPP had a postoperative mortality of 10.5%, vs. 3.1% with P/D.

Other short-term risks include infection, fluid accumulation in the remaining lung, pneumonia, blood clots, internal bleeding, kidney failure, heart problems and pus accumulation in pleural space. Some patients may also suffer from shortness of breath, which could mean they become dependent on an oxygen tank or mechanical respirator in the long-term.

Due to the severity of the operation, recovery from an EPP is slow. After two weeks in the hospital, patients are advised to do very little during the first six to eight weeks at home. Rest is incredibly important as the remaining lung needs ample time to adjust.

For more information on mesothelioma surgeries and treatment options, contact our Victims Advocates today.

View Author and Sources
Sources
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    Retrieved from: http://www.jtcvsonline.org/article/S0022-5223(14)00318-3/fulltext
    Accessed on February 09, 2018
  2. 2017 study at the Baylor Scott & White Medical Center: "Intensity modulated radiation therapy after extra-pleural pneumonectomy for malignant pleural mesothelioma is feasible without fatal pulmonary toxicity and provides good survival"
    Retrieved from: http://onlinelibrary.wiley.com/doi/10.1111/ajco.12680/abstract
    Accessed on February 09, 2018
  3. Mesothelioma Guide.
    Retrieved from https://www.mesotheliomaguide.com/treatment/surgery/debate/
    Accessed on February 09, 2018
  4. NCBI: "Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma"
    Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153961/
    Accessed on February 09, 2018
  5. UCLA Health, "Robert B. Cameron, MD"
    Retrieved from: https://www.uclahealth.org/robert-cameron.
    Accessed on January 31, 2018

Last modified: August 30, 2018