Extrapleural Pneumonectomy

What Is an Extrapleural Pneumonectomy?

The extrapleural pneumonectomy, or EPP, is a surgery for early-stage pleural mesothelioma. It is for patients whose cancer is still in the chest cavity.

This procedure aims to remove as much cancerous tissue as possible. Unfortunately, many patients are diagnosed only after their cancer has progressed to stage 3 or 4. This makes them ineligible for this surgery.

An EPP can improve breathing and quality of life. After recovery, patients often feel more at ease. This allows them to return to their daily activities or even resume work.

Some doctors believe that EPP often removes all visible cancer. But many mesothelioma specialists say this aggressive approach may be outdated. They point to newer techniques, like lung-sparing pleurectomy/decortication, as a safer, promising alternative.

Benefits of an Extrapleural Pneumonectomy

The EPP procedure can be a helpful option for mesothelioma patients, as it removes a lot of the cancerous tissue. This can lead to an increased life span, especially when paired with chemotherapy or radiation. Many patients see improvements in their lives by living for several extra months or even years.

In a 2017 study at the Baylor Scott & White Medical Center, patients who received a combination of EPP and intensity-modulated radiation therapy (IMRT) enjoyed a median survival of 38.2 months, with a median relapse-free survival of 24.4 months. These results show the potential benefits of this approach.

While there is currently no cure for mesothelioma, EPP has proven to be an effective way to manage this type of cancer for certain patients. It can help slow the cancer’s progression and improve breathing, which greatly enhances quality of life. By using high-dose radiation therapy after EPP, doctors can often help prevent the cancer from coming back in the same area.

A 2022 study found that, when used as part of a broader treatment plan, EPP had similar long-term outcomes to another procedure called pleurectomy and decortication. However, it is important to note that EPP had higher mortality rates after surgery. The study encourages patients to choose the safest treatment option that they can handle.

Surgical Consultation for EPP

The benefits and risks of an EPP will be discussed at a consultation with the surgeon and the surgical team.

The consultation serves as an opportunity for you and the surgical team to talk about your questions and concerns, and it can be done in person or virtually. They will review your medical records, imaging scans and biopsy test results. The doctors will also discuss details of the procedure, including recovery.

EPP Risks and Drawbacks

EPP surgery can offer hope for patients, but it’s important to understand the most serious risk is death after surgery. A study from 2014, which included multiple centers and followed 255 pleural mesothelioma patients, found that the mortality rate for EPP was higher than that of the less invasive P/D procedure. Specifically, 10.5% of patients who had EPP experienced postoperative mortality within 30 days, compared to 3.1% for those who had P/D.

Additionally, complications can arise after EPP surgery. The study reported a morbidity rate of 24.2% for EPP, while P/D had a much lower rate of 3.8%. Notably, nearly 10% of EPP patients required an unexpected return to the operating room, compared to just 1.5% for P/D patients.

Another important consideration is the possibility of cancer recurrence after EPP. According to a 2012 study on multimodal therapy for mesothelioma, local recurrence can occur in up to 80% of patients. However, this rate improves to 13% when patients receive radiation therapy after surgery. Nonetheless, recurrence at distant sites can still affect up to 55% of patients.

Short-Term EPP Risks

Other risks of EPP for mesothelioma include blood clots, heart problems and pneumonia, among others. Understanding these risks can help patients and their families make informed decisions about their treatment options.

Common Short-Term EPP Risks

• Wound infection
• Pneumonia
• Fluid accumulation in lungs
• Blood clot in the lungs
• Pus accumulation in pleural space
• Kidney failure
• Abnormal connection between the bronchial cut and pleural space
• Heart problems (cardiac arrhythmias and heart attack)

Long-term risks can include shortness of breath. This might lead to needing an oxygen tank or a mechanical respirator for a while after surgery.

It’s important to watch for signs of serious issues that may arise after an EPP. These signs include fever, chest pain, a cough, and shortness of breath. If your incision becomes red, swollen, painful, or starts to ooze blood, these could also be warning signs. If you notice any of these symptoms, please reach out to your doctor right away. 

About the Procedure

Before performing the extrapleural pneumonectomy surgery for mesothelioma, doctors carry out important tests to ensure that the remaining lung will be strong enough to work well on its own. They also check the patient’s heart health to confirm they are fit for major surgery.

The EPP surgery is done under general anesthesia. The surgeon makes a careful incision, about 9 to 10 inches long, on the side of the chest. After this, the doctor will remove the sixth rib and use a rib spreader to look for any diseased tissue. They aim to remove as much cancerous tissue as possible, which includes the entire cancerous lung, parts of the heart lining (pericardium), the diaphragm, the lining of the lung (pleura), and any nearby lymph nodes.

Additional tests, like a PET/CT scan, help doctors see if the cancer has spread beyond the lungs.

What to Expect After Surgery

Recovering from an EPP can take some time. In some cases, patients may need a respirator to help with breathing for the first few days after surgery. Additionally, drainage tubes will be in place for one to two days to help monitor for any bleeding or air leaks.

Most patients stay in the hospital for at least two weeks following the operation. During this time, the medical team will keep a close eye on you, as it is common to experience some complications.

Overall, the recovery period lasts at least 6 to 8 weeks, but it may extend longer for some. It’s important to start moving and take deep breaths, as this helps your remaining lung function well.

Even 6 months after surgery, you might notice that exercise can still feel challenging due to shortness of breath. Remember, this is all part of the healing journey, and with time, you will likely feel stronger.

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