Extrapleural Pneumonectomy
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Extrapleural pneumonectomy (EPP) is a radical and invasive surgery for pleural mesothelioma that includes removal of an entire lung and pleural tissue along with lymph nodes and part of the diaphragm.[1] Only patients in generally good health and whose cancer has not spread extensively are considered good candidates for this risky but potentially curative procedure.
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.[2]
Because EPP is such a complicated and specialized procedure, not all surgeons perform it. It requires tremendous expertise. Successful EPP requires removing as much cancerous tissue as possible, along with any healthy tissues that may be affected.
This means surgeons remove one entire lung with its covering of pleural tissue. Depending on the patient, surgeons may also remove part of the pericardium (tissue around the heart), diaphragm, and lymph nodes.[2]
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 remaining lung.[2]
Potential Benefits
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. The five-year survival is 56 percent for mesothelioma patients undergoing EPP.[2]
In recent studies, researchers have used EPP as part of an approach known as SMART, or Surgery for Mesothelioma After Radiation Therapy. Results from a Canadian trial included a median overall survival time of 24.4 months and a disease-free survival time of 18 months.[3]
Besides being potentially curative, EPP can also relieve symptoms of mesothelioma. Removing diseased tissue can reduce pleural effusions (the buildup of fluid around the lungs), chest pain, shortness of breath, and other symptoms.
Relief from symptoms can improve the patient’s quality of life; although, it must be balanced against the issues associated with 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. A review of EPP studies found that the mortality rate for mesothelioma patients is up to 11.8 percent after this surgery.[2]
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.[4]
About one-third of EPP patients experience serious complications.[1] Even if the surgery goes well, the cancer may reappear. Oncology teams may be able to lower the rate of recurrence with post-surgery radiation therapy.[5]
Some researchers have found survival times to be less for EPP than for a less radical surgery called pleurectomy and decortication. These experts believe the latter should be used and is preferable to EPP.[6]
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.[1]
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 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 risk of 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 up to two weeks 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 one only has one lung.[7]
Many experts have conflicting opinions concerning EPP, preferring less radical treatment alternatives; however, potential benefits are tremendous.
While few patients are candidates for this radical procedure, they need to understand it and its associated risks.
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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.