Extrapleural Pneumonectomy

An extrapleural pneumonectomy, or EPP, is an extremely invasive and extensive surgery that comes with many risks to the patient. It may also be a patient’s only hope at beating an aggressive cancer. EPPs are almost exclusively performed on patients with pleural mesothelioma, and not many patients with this type of cancer are eligible for this risky and long surgery.

Only patients in general good health, who are young enough, and who have not seen their cancer spread too far from the original site are good candidates for an EPP. The surgery is an aggressive way to treat an aggressive cancer and it involves removing an entire lung along with the pleura, part of the diaphragm, and other tissues. The risks are high, but the outcome could be remission.

What Is an EPP?

An extrapleural pneumonectomy is an extensive surgery that removes much of the tissue from the chest cavity. While today it is almost always used for patients with mesothelioma, the procedure was first performed in the 1940s and was used to try to treat people with severe tuberculosis. Then it was risky and dangerous and resulted in a lot of mortalities. Today it is still risky, but methods and medicines have improved enough that survival rates are much higher than they were in the past.

Not all surgeons perform EPPs because it is a highly specialized procedure that requires expertise. The procedure includes the removal of as much cancerous tissue as possible, along with healthy tissues that may be affected by the cancer. This means that one entire lung with its covering pleural tissue is removed. Also removed, depending on the patient, is part of the pericardium, the tissue around the heart, part of the diaphragm under the affected lung, and lymph nodes that are near the lung.

The surgery also usually includes the reconstruction of the diaphragm with prosthetic components. An artificial diaphragm is needed to help the patient breathe with the remaining lung. The diaphragm is a muscle that contracts and relaxes to help force air out of the lungs. It is an essential part of breathing correctly and getting enough oxygen in the body.

Potential Benefits

Although an EPP is highly risky and may even lead to a fatality, for some patients these are worth the possible benefits. This extensive removal of tissue is one of the few ways known to achieve remission for pleural mesothelioma. It is also one of the most effective ways of extending the life span of someone with a pleural mesothelioma diagnosis. Even if the cancer recurs, the surgery can give a patient several extra years of life, especially when it is combined with chemotherapy, radiation therapy, or both.

In addition to the possibility of being curative or at least extending life significantly, an EPP can also bring relief from symptoms of mesothelioma. Removing the diseased tissue can reduce pleural effusions—the buildup of fluid around the lungs—chest pains, shortness of breath, and other symptoms. This in turn improves the quality of life for the patient, although it must be balanced against the symptoms caused by having only one lung.

Risks of EPP

The risks of this radical surgery are high. Removing so much tissue from the body, including an entire organ makes a patient vulnerable to a number of complications. The most pressing complication is death. Nearly seven percent of patients who undergo an extrapleural pneumonectomy will die during or soon after the surgery. Less invasive surgeries for treating mesothelioma have death rates closer to three percent.

Other risks that patients undergoing an EPP face include long-term breathing difficulties and shortness of breath, which may necessitate the use of an oxygen tank indefinitely. Patients also face serious infections, pneumonia, blood clots, accumulation of fluid or pus in the pleural space, and heart problems. Up to one in three people undergoing an EPP will experience serious complications.
Even if the surgery goes well, the patient survives, and there are no serious complications, a recurrence of the cancer is possible. The goal is to eliminate the cancer entirely and go into remission, but some patients will see a recurrence. The rate of recurrence can be lowered with post-surgery radiation therapy, but there is always a good chance that the cancer will eventually come back, sometimes in a different part of the body.

Candidates for Extrapleural Pneumonectomy

Not many people will ever undergo an EPP because pleural mesothelioma is a rare disease. Even among those living with mesothelioma, not all are eligible for the procedure. Patients have to be healthy and young enough and able to withstand both the surgery and the necessary post-surgical treatments like radiation and chemotherapy.

Many patients fail to be good candidates for an EPP because of other conditions, such as heart disease, diabetes, or simply frailness due to aging. Another disqualifying factor is advanced disease. If the cancer has spread to lymph nodes more distant than those closest to the affected lung or to other parts of the body and other organs, an EPP will not help and its benefits are not worth the serious risks.

Life after Extrapleural Pneumonectomy

Recovery from an EPP can be long and slow. A patient may need some time to recover, but will soon be faced with undergoing radiation or chemotherapy to reduce the risks of the cancer recurring. The patient may also need time on a respirator and may have to have fluids drained from the chest cavity regularly while recovering.

There are such serious potential complications with an EPP that patients must spend at least a couple of weeks in the hospital for monitoring. Full recovery, if possible, requires up to eight weeks or even more time. Even after this period a patient may never be fully recovered and may live with breathing difficulties and limitations on being physically active.

While the risks are high for an EPP, and experts debate whether this surgery is any better than less radical alternatives, the potential benefits could be life-saving. Only a few patients will be candidates for an EPP and they face a long uphill battle to feeling well again. If you are a candidate for this procedure, make sure you understand everything it entails and that you are prepared to take the risks.