Extra pleural pneumonectomy, often referred by the initials EPP, is a type of aggressive surgical treatment for malignant pleural mesothelioma and certain lung cancers. A pneumonectomy is a surgical procedure where either the 3 lobes that make up the right lung or the 2 lobes that make up the left lung is removed depending on what side the tumor is located on. A pneumonectomy was one of the treatments offered in 1949 for treatment of patients who had a tuberculosis empyema (infection). An extra pleural pneumonectomy is a procedure in which one of the lungs is removed along with part of the diaphragm, the pleura- the lining of the chest cavity-, and sometimes the pericardium, the lining around the heart. Within the last 30-40 years it is a procedure that is used to treat mesothelioma almost exclusively.
The goal of an EPP is to remove all the tumor that is visible to the surgeon. At some centers once all the tumor that can be seen, referred to as macroscopic tumor removal, is removed a chemotherapy wash is then done in the operating room. The rationale for Intra-Operative Heated Chemotherapy, sometimes referred to as HIPEC, is to then treat the cells that cannot be seen that are there.
A pneumonectomy or an extra pleural pneumonectomy are usually recommended after extensive testing. The testing includes lung function tests, to see if the patient is able to withstand breathing with one lung. A cardiac workup, extensive testing to the cell type and stage of the disease are all performed and analyzed. Some of the other tests that can be performed before surgery include a bone scan, brain scan, abdominal scan to see that there is no spread of the cancer to other organs. Tests are performed to see if there is any distant or contralateral disease on the non-operative lung. Arterial blood gasses are performed along with other extensive blood work. Pleural mesothelioma patients that have early disease, epithelial cell type, good functional status, and no lymph node involvement can be possible candidates for this procedure. Where the tumor is located in the lung is also a factor that the medical team will take into account. The medical team will also evaluate the patient’s ability to withstand multi-modality therapy, surgery, chemotherapy, and radiation.
At the time of the biopsy the surgical team will perform a thoracosopy with a talc pleurodesis on a candidate that may potentially be a candidate for an EPP. This procedure can help with the potential surgical resection of an EPP and help reduce the chance of the fluid reaccumulating and confirm the biopsy. It is usually performed 2-3 weeks prior to the surgery.
EPP’s are extensive surgeries. Complications following the surgery can include cardiac arrhythmias, pulmonary embolus, and bronchopleural fistulas, along with other complications.
There are ongoing discussions regarding the choice of Extra Pleural Pneumonectomy vs. Pleurectomy. Research has shown that the decision of one procedure or the other should be patient specific, depending on the cell type, metastases to other areas, and ability of the patient to withstand multimodal therapy.
Extra pleural pneumonectomies for patients with malignant pleural mesothelioma should be performed at a mesothelioma center with an experienced team, after extensive workup of the patient.
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