What is a Extrapleural Pneumonectomy for Mesothelioma?
Extrapleural pneumonectomy (EPP) is a form of radical surgery to treat mesothelioma. The treatment is somewhat controversial because it is so radical but several studies have shown that certain types of mesothelioma patients may greatly benefit from EPP surgery. Most often this approach is part of a combined multimodal treatment for pleural mesothelioma which may also include chemotherapy and even some form of radiotherapy.
What is Extrapleural Pneumonectomy?
EPP is a surgical procedure during which the patient’s entire lung, portions of the diaphragm, the parietal pleura (the membrane around the lungs), and possibly portions of the pericardium (the membrane surrounding the heart) are removed. The goal of this procedure is to completely eliminate all of the cancerous mesothelioma cells within the body.
What is the Procedure for EPP?
- The first step is always pre-surgical imaging. Mesothelioma doctors will order imaging tests, usually PET or CT scans, so they can get a clear picture of what exactly awaits inside the chest. This will allow them to see where mesothelioma tumors have formed and what tissues are diseased. This will also allow them to plot out the scope of the surgery and estimate survivability and prognosis for the individual patient. Note: Other forms of imaging such as x-rays or sonograms may also be used but generally the imaging from these procedures is not detailed or accurate enough to base further treatment on.
- The second general step is the actual surgical procedure itself. During this process, surgeons open the chest via a large incision, either at the sternum – breastbone – or at the side, and physically remove the affected lung (usually the right) and the surrounding pleural tissue. In most cases the mesothelioma will have spread to the diaphragm and possibly the pericardium. If it has, the surgeon will then make the decision whether or not to remove this tissue and how much to remove.
- The next step varies between patients, but usually includes some form of chemotherapy. Either patients receive chemotherapy treatments while still on the operating table, called perioperative chemotherapy, or they receive treatments immediately afterward. This immediate dosage allows doctors the best possible opportunity to eliminate invisible cancer cells that may be free-floating within the chest cavity of surroundings.
Because the surgery is so invasive, patients experience an extended recovery period. They may need to stay in hospital for anywhere from two weeks to several months. In addition, it may take anywhere from six weeks to several months to fully recover.
Who Can Benefit from EPP?
Because the nature of this surgical procedure is to eliminate diseased tissue, the surgery is only offered to patients suffering from localized mesothelioma. Those patients whose cancer has already metastasized (travelled to the lymph nodes and other portions of the body) will not benefit from the procedure.
In addition, because of the risk associated with EPP, surgery is usually reserved for relatively healthy patients. Patients suffering from additional illnesses or those with weakened immune systems, respiratory functions, cardiac functions, renal functions, or other ailments do not qualify for this procedure because the risks often outweigh the benefits.
Risks of Extrapleural Pneumonectomy
EPP shares a risk profile with many other such radical surgical procedures. These risks include:
Complications during the procedure (including excessive bleeding, hypothermia, accidental death)
- Adverse reactions to the anesthetic
- Increased risk of infection during or after the procedure
- Increased risk of morbidity (diseases or ailments caused by the procedure)
- Increased risk of blood clots, internal bleeding, and reduced organ function
In general, the surgery itself carries a 6% risk of death during or immediately after the procedure. However, that figure is strongly influenced by a number of factors including the patient’s overall health, the extent to which the cancer has permeated the tissue, and the ability of the remaining lung to handle the increased workload.
Benefits of EPP
Though the risks for this type of radical surgery are great, multiple studies have shown that it can indeed benefit certain types of mesothelioma patients. By removing the diseased tissue, surgeons can increase longevity and improve the quality of life of certain mesothelioma patients.
Those patients who undergo EPP combined with perioperative or post-operative chemotherapy fair the best.
Controversy Surrounding Mesothelioma and EPP
Some recent studies have shed doubt on treating mesothelioma with EPP. These studies focus on survival rates and quality of life issues that many EPP patients face after their surgical procedure. These studies have swayed some mesothelioma experts into recommending that EPP remain only as a “last ditch” effort in curative treatment for the disease. These experts cite studies that list less-invasive procedures such as full or partial resection of the pleura (called a pleurectomy) as better options for most patients due to decreased risk profile with similar benefits.
However, even those experts against EPP maintain that the procedure may indeed be the best option for some individual patients. This debate points directly back to the highly personalized nature of this disease. No two cases are alike and every individual’s treatment plan should be custom tailored to suit their needs and expectations.