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An extrapleural pneumonectomy (EPP) is a radical and invasive surgery with serious risks. However, EPP may be a patient’s only hope at beating aggressive cancers like mesothelioma. EPPs are almost exclusively performed on patients with pleural mesothelioma. Even so, few patients are eligible for this long, risky procedure. Only younger patients in generally good health and whose cancer has not spread extensively are considered good candidates. The surgery involves removing an entire lung with attached pleura, part of the diaphragm, and other tissues. It is an extremely aggressive way to treat an extremely aggressive cancer.
What Is an EPP?
An extrapleural pneumonectomy removes much of the tissue from the chest cavity. While today it is most commonly used for mesothelioma patients, the procedure was first performed to treat severe tuberculosis. Originally, it was so dangerous that many patients died from the procedure. While it remains risky today, improved methods and medications have significantly increased survival rates.
Because EPP is such a complicated and specialized procedure, not all surgeons perform it. It requires tremendous expertise. Successful EPP requires the removal of as much cancerous tissue as possible, along with any healthy tissues that may be affected. This means surgeons will remove one entire lung with its covering of pleural tissue. Depending on the patient, part of the pericardium (tissue around the heart), diaphragm, and lymph nodes may also be removed.
EPP usually includes reconstruction of the diaphragm with prosthetic components as part of the procedure. The diaphragm is a muscle that contracts and relaxes to force air in and out of the lungs. It is an essential part of the breathing process. Therefore, an artificial diaphragm will help the patient breathe with the one remaining lung.
Although EPP is incredibly risky, for some, the possible benefits outweigh the risks. Extensive tissue removal is one of the few ways known to achieve remission for pleural mesothelioma. It is also one of the most effective ways to extend the life expectancy of a patient with this devastating disease. Even if cancer recurs, the surgery can give a patient several extra years of life, especially when combined with chemotherapy, radiation therapy, or both.
Besides being potentially curative, EPP can also relive symptoms of mesothelioma. Removing diseased tissue can reduce pleural effusions )the buildup of fluid around the lungs), chest pains, shortness of breath, and other symptoms. Relief from symptoms can improve the patient’s quality of life, although it must be balanced against the problem of having only one lung.
Risks of EPP
Risks associated with this radical surgery are high. Removing significant tissue from the body, including an entire organ, makes a patient vulnerable to several serious complications. Death is a real possibility. Nearly 7 percent of patients who undergo an extrapleural pneumonectomy die during or soon after surgery. However, less invasive surgeries for treating mesothelioma kill about 3 percent of patients.
Patients undergoing EPP may also suffer long-term breathing difficulties, which may necessitate supplemental oxygen. Patients also risk serious infections, pneumonia, blood clots, accumulation of fluid or pus in the pleural space, and heart problems. About one third of EPP patients experience serious complications. Even if the surgery goes well, the cancer may reappear. The rate of recurrence can be lowered with post-surgery radiation therapy.
Candidates for Extrapleural Pneumonectomy
Because pleural mesothelioma is so rare, few patients will ever undergo EPP. Even among those with mesothelioma, not all are good candidates for the procedure. Patients must be healthy and young enough and withstand both the surgery and required post-surgical treatments. Many patients fail to qualify for EPP due to other conditions, such as heart disease, diabetes, or old age.
Advanced disease could also affect a patient’s eligibility for EPP. If the cancer has spread to lymph nodes distant from the affected lung, or if it has spread to other organs, EPP is not a practical option.
Life after Extrapleural Pneumonectomy
Recovery from EPP is usually long and slow. Even as a surgical patient recovers, they will undergo radiation or chemotherapy to reduce the risks recurrence. Some may need supplemental oxygen, physical rehab, and close monitoring of long term side effects. A strong support system is helpful.
There are such serious potential complications with EPP that patients must spend several days in the hospital for monitoring. Full recovery requires up to eight weeks or longer. Even then, a patient may never fully recover, experiencing breathing problems especially when physically active. Patients are at higher risk of complications for months to years after surgery. Things such as swallowing issues and pneumonia must be treated aggressively, as both can be deadly when only one lung.
Many experts have conflicting opinion concerning EPP, preferring less radical treatment alternatives. However, potential benefits are tremendous.
While few patients are candidates for this radical procedure, it is important for them to understand the procedure and its associated risks.
Page Medically Reviewed and Edited by Anne Courtney, AOCNP, DNP
Anne Courtney has a Doctor of Nursing Practice degree and is an Advanced Oncology Certified Nurse Practitioner. She has years of oncology experience working with patients with malignant mesothelioma, as well as other types of cancer. Dr. Courtney currently works at University of Texas LIVESTRONG Cancer Institutes.