Extrapleural Pneumonectomy
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Extrapleural pneumonectomy (EPP) is a surgery for pleural mesothelioma that removes an entire lung, pleural tissue, 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.
The Definition of Extrapleural Pneumonectomy
Extrapleural pneumonectomy, or EPP, is a surgery that removes a lung and other tissue including parts of the pleura, pericardium, lymph nodes, and diaphragm.
What Is a Pneumonectomy?
Pneumonectomy is a surgery that removes a lung. A surgery that only removes part of a lung is a lobectomy or resection.
Surgeons most often use pneumonectomy to treat cancer, including lung cancer and pleural mesothelioma. It can also be used to treat some other types of lung disease and serious lung injuries.
What Does Extrapleural Mean?
Pleural tissue lines the lungs in the chest cavity and is the site of origin of pleural mesothelioma. Extrapleural refers to the space in the chest cavity beyond the lungs and pleura.
In terms of extrapleural pneumonectomy, extrapleural means that the procedure removes more than just the lung. A surgeon might remove part of the diaphragm, lymph nodes, and other tissue in the chest cavity with cancerous tumors.
About Extrapleural Pneumonectomy Surgery
An extrapleural pneumonectomy removes a lung and much of the extrapleural tissue from the chest cavity. It is a radical and risky surgery used to treat serious and life-threatening illnesses.
The History of Extrapleural Pneumonectomy
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]
Extrapleural Pneumonectomy Requires Special Expertise
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.
What Happens During Extrapleural Pneumonectomy?
During the procedure, a surgeon removes 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]
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 to 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.
What Are the Benefits of Extrapleural Pneumonectomy?
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.
Extending Life Expectancy
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]
Relieving Symptoms of Pleural Mesothelioma
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.
What Are the Risks of Extrapleural Pneumonectomy?
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.
Potential Complications
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]
How Common Are Serious Complications with Extrapleural Pneumonectomy?
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]
What Is the Mortality Rate for Extrapleural Pneumonectomy?
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]
Other sources report that 6% of patients die either during or immediately after surgeons complete the procedure.[6]
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.[7]
Is Extrapleural Pneumonectomy Worth the Risks?
The potential risks of this surgery are serious and even life-threatening. On the other hand, pleural mesothelioma is almost always terminal.
Whether this procedure is worth the risks is a personal decision. Many surgeons will not perform it, both because of the complications and possibility of death and the fact that it requires special expertise.
Discuss the procedure with your medical team and family. If you decide to undergo it, choose a surgeon with the appropriate expertise and experience performing it.
Alternatives to Extrapleural Pneumonectomy
There is no single formula for treating pleural mesothelioma. Every patient’s situation is unique with specific challenges. If you are a candidate for surgery but feel EPP is too risky, less invasive and radical surgeries are available.
The most common alternative is called pleurectomy/decortication. This is less aggressive and involves removing the pleural tissue and any visible tumors. The surgeon can scrape tissue off the lung’s surface rather than remove the entire organ.
You might also choose not to have any type of curative surgery. Patients can opt for palliative procedures only. The goal of these surgeries is to improve symptoms and quality of life.
Recovering from Extrapleural Pneumonectomy
EPP is the most extensive surgery available for pleural mesothelioma, so the recovery is lengthy and difficult. You could spend anywhere from two weeks to months in the hospital depending on the presence of any complications.
While in the hospital, the staff will monitor you closely for complications. After leaving the hospital, you will need assistance at home for weeks to months. Your activities will be limited and you will have several follow-up appointments with your surgeon.
Your surgeon will prescribe medications, like painkillers. They will also provide you with an expected timeline for recovery and exercises to aid recovery. Report any side effects, complications, or problems immediately.
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. Recovery can take months.
Even then, a patient may never fully recover. Living with one lung, you could have permanent 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.[8]
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.