Extrapleural Pneumonectomy (EPP)

Quick Summary

Extrapleural pneumonectomy is the surgical removal of the lung and chest cavity tissue for early-stage pleural mesothelioma patients. It is a curative procedure that offers the lowest probability of recurrence (when the mesothelioma comes back), and can possibly extend the patient’s life.

Extrapleural Pneumonectomy Overview

During an extrapleural pneumonectomy (EPP), the surgeon will remove the affected lung, part of the diaphragm, parts of the lining of the heart (pericardium) and lung (pleura), and nearby lymph nodes. The surgery is extensive and invasive, and the main goal is to remove all the diseased tissue.

EPP was originally developed for tuberculosis treatment and later became the first surgery offered to mesothelioma patients. The procedure has been adjusted and improved over the decades as new research surfaces.

Patients may be good candidates for EPP if they have early-stage pleural mesothelioma and are in otherwise good health. EPP is an aggressive surgery undertaken by the most skilled surgeons at top medical centers around the country.

Extrapleural pneumonectomy—when successful and undertaken in good candidates—has shown to extend life expectancy by months and in some cases years. However, the surgery carries a substantial risk for complications.

Who Is Eligible for Extrapleural Pneumonectomy?

In most cases, only patients with stage 1 or stage 2 mesothelioma are eligible for extrapleural pneumonectomy. Removing the lung makes sense only if the mesothelioma is contained to the chest and has not metastasized (spread) to other parts of the body—a process which happens in advanced stages.

Patients must be in good overall health to handle the surgery.

Some considerations include:

  • Age—younger patients are typically better candidates
  • Gender—women generally have better survival and recovery rates
  • Other health conditions
  • Whether you are a smoker
  • General fitness level

In some cases, patients with stages 3 and 4 mesothelioma may be considered eligible for EPP. However, the goal in later stages shifts to relieving symptoms and improving quality of life rather than sending the disease into remission.

Living with a single lung presents challenges—the severity differing from patient to patient. Debate exists among healthcare professionals about whether lung removal is an effective course of treatment. As each mesothelioma case is unique, it crucial that you discuss the surgical treatment options with your medical team to determine the optimal plan.

Benefits of Extrapleural Pneumonectomy

For patients deemed eligible for extrapleural pneumonectomy, surgery could provide the greatest chance of extending your life. Removing as much mesothelioma as possible decreases the probability of metastasis and recurrence. The recurrence rate after the EPP is 33%.

The average life expectancy following EPP is 10 to 35 months. Combining surgery with other treatments such as chemotherapy and radiation may further increase life expectancy. Some studies show over 20% of patients surviving five years after the EPP surgery.

The surgery often reduces troublesome mesothelioma symptoms, such as difficulty breathing, which improves patients’ quality of life and allows them to continue some tasks and hobbies that were previously impossible. Therefore, the surgery is also beneficial in a palliative nature, and patients in stage 3 and stage 4 may be candidates for EPP if they satisfy the overall health requirements.

Extrapleural Pneumonectomy Procedure

Extrapleural pneumonectomy is a major surgery that involves extensive medical processes before, during, and after the operation.

Before Surgery

As mentioned, patients must be in good general health to undergo EPP. Before the surgery, doctors will run routine tests to ensure your body is strong enough for the procedure and recovery process. In particular, lung function is tested to gauge how well you can withstand living with a single lung. Doctors will also confirm that cancer remains in the chest cavity.

During Surgery

EPP is an open surgery performed under general anesthesia in a large medical center. The surgeon makes an incision of 6 to 10 inches at the front or side of the chest to access the lung space. The surgeon then removes the affected lung, as well as portions of the lung and heart linings and the diaphragm, while also searching for other diseased tissue in the area.

The operation varies slightly depending on whether the left or right lung is removed. Great care is taken to resect (remove) the diseased tissue without contaminating unaffected areas. The surgery takes about three hours to complete.

Recovery

Recovery from EPP is usually lengthy. Most patients remain in the hospital for up to two weeks after surgery, followed by three months’ recovery at home. Patients use a respirator for the first few days to aid breathing, and an IV administers fluids and medications. Doctors will closely monitor you for signs of infection and complications affecting the heart and remaining lung.

Breathing exercises and physical therapy often begin soon after the procedure. After returning home, you must continue a regimen of rest and rehabilitation. Living with one lung will be difficult at first, but most patients adapt over time.

EPP as Part of Multimodal Therapy

Lung-removal surgery is most effective when combined with additional mesothelioma treatments.

Your medical team may suggest one or more of the following options to accompany your EPP surgery:

  • Chemotherapy: Powerful drugs administered by IV (intravenous) to kill any cancer cells remaining after EPP. Chemotherapy may also be prescribed before surgery to shrink tumors.
  • Radiation: Known to shrink tumors and decrease cell replication rate. Radiation can be delivered precisely, allowing for high-dose treatments without damaging nearby tissue. Radiation is also used to relieve pain.
  • Alternative treatments: Used most often to relieve discomfort and symptoms. Alternative treatments are not curative but aid your overall ability to fight cancer. Options may include special nutrition and herbal medicines, yoga, massage and physical therapy.

EPP Risks and Side Effects

Extrapleural pneumonectomy is an extensive procedure, and it is essential that patients are aware of the potential risks and side effects. Up to 33% of patients who undergo EPP experience a complication.

Possible EPP risks and side effects include:

  • Pain at the incision site
  • Blood clotting
  • Bleeding (internal or external bleeding, normally controlled)
  • Damage to nearby tissue and organs
  • Infections (at the incision site or internally at the site of operation)
  • Pneumonia

Operating on and near vital organs carries an increased probability of serious risks during and after the surgery, including cardiac and respiratory failure. Doctors will closely monitor you for signs of these complications.

Patients may also experience side effects associated with general anesthesia, such as nausea, dizziness, discomfort, and temporary confusion. In rare cases, general anesthesia causes serious reactions, including rapid fever, delirium, and cognitive dysfunction.

For select patients, extrapleural pneumonectomy offers the greatest chance of mitigating recurrence and extending life expectancy. Combined with multimodal approaches, EPP may be the best treatment course for you. Contact our Patient Advocates today for more information about surgery options for pleural mesothelioma.

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Sources
  1. Expert Review of Respiratory Medicine, “Surgery for Malignant Pleural Mesothelioma.” Retrieved from: https://www.medscape.com/viewarticle/724140. Accessed on February 12, 2018.
  2. European Journal of Cardio-Thoracic Surgery, “Outcome after extrapleural pneumonectomy for malignant pleural mesothelioma.” Retrieved from https://academic.oup.com/ejcts/article/34/1/204/354565. Accessed on February 12, 2018.
  3. OncoTargets and Therapy, “The evolution of the diminishing role of extrapleural pneumonectomy in the surgical management of malignant pleural mesothelioma.” Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5135403. Accessed on February 12, 2018.
  4. University of California San Francisco, “Extrapleural Pneumonectomy.” Retrieved from: https://thoracic.surgery.ucsf.edu/conditions--procedures/extrapleural-pneumonectomy.aspx. Accessed on February 12, 2018.

Last modified: May 7, 2018