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Extra Pleural Pneumonectomy (EPP)

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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Did You Know?

  • Mesothelioma Facts
    Mesothelioma Facts
    The highest award of compensatory damages ever upheld on appeal in a mesothelioma case is $30.3 million.
  • Mesothelioma Facts
    Mesothelioma Facts
    The largest punitive damages verdict ever upheld on appeal in a mesothelioma case is $18 million.
  • Mesothelioma Facts
    Mesothelioma Facts
    There are over $30 billion in asbestos trust funds to compensate victims of mesothelioma and other asbestos-related diseases.
  • Mesothelioma Facts
    Mesothelioma Facts
    There are more than 50 bankruptcy trusts accepting claims to compensate victims of mesothelioma and other asbestos-related diseases.
  • Mesothelioma Facts
    Mesothelioma Facts
    There are many “asbestos dockets” that permit living mesothelioma patients to obtain a jury verdict in less than 1 year.
  • Mesothelioma Facts
    Mesothelioma Facts
    In 2015, more than 2000 mesothelioma cases were filed in the United States.
  • Mesothelioma Facts
    Mesothelioma Facts
    In some mesothelioma cases, settlements can be obtained in less than 1 year.
  • Mesothelioma Facts
    Mesothelioma Facts
    Thousands of different companies have been defendants in mesothelioma cases over the past 40 years.
  • Mesothelioma Facts
    Mesothelioma Facts
    According to a 2015 study of 77 peritoneal mesothelioma cases, the average life expectancy (median survival period) was 75.7 months, or over 6 years.
  • Mesothelioma Facts
    Mesothelioma Facts
    According to a 2015 study of 77 peritoneal mesothelioma patients, 73.8% were living after 3 years, and 65.3% were living after 5 years.
  • Mesothelioma Facts
    Mesothelioma Facts
    According to a 2015 study of 77 peritoneal mesothelioma patients, 64% were treated with HIPEC and cytoreductive surgery.
  • Mesothelioma Facts
    Mesothelioma Facts
    According to a 2015 study of 303 pleural mesothelioma patients, the average life expectancy (median survival period) was 18.4 months.
  • Mesothelioma Facts
    Mesothelioma Facts
    According to a 2015 study of pleural mesothelioma patients, 73.1% were still living after 1 year, and 22.9% were still living after 3 years.
  • Mesothelioma Facts
    Mesothelioma Facts
    In 2015, the largest number of mesothelioma cases were filed in the following 10 courts: (1) Madison County, IL; (2) Cook County, IL; (3) St. Louis, MO; (4) Los Angeles, CA; (5) New York, NY; (6) Philadelphia, PA; (7) New Castle County, DE; (8) Middlesex County, MA; (9)Middlesex County, NJ; (10) Kanawha County, WV.
  • Mesothelioma Facts
    Mesothelioma Facts
    The states with the largest number of diagnosed mesothelioma cases are: New York, New Jersey, California, Washington, Pennsylvania, Massachusetts, Virginia, Florida, Texas, Illinois, Wisconsin, Michigan and Ohio.
  • Mesothelioma Facts
    Mesothelioma Facts
    There are about 3000 mesothelioma cases diagnosed in the United States each year.
  • Mesothelioma Facts
    Mesothelioma Facts
    About 1 in 100,000 people in the United States will be diagnosed with mesothelioma each year in the United States.
  • Mesothelioma Facts
    Mesothelioma Facts
    More than 80% of all mesothelioma cases occur in the pleura (pleural mesothelioma).
  • Mesothelioma Facts
    Mesothelioma Facts
    Less than 20% of all mesothelioma cases occur in the peritoneum (peritoneal mesothelioma).
  • Mesothelioma Facts
    Mesothelioma Facts
    About 22% of all mesothelioma cases occur in women.
  • Mesothelioma Facts
    Mesothelioma Facts
    A history of asbestos exposure can be found in more than 80% of mesothelioma cases.
  • Mesothelioma Facts
    Mesothelioma Facts
    More than 30% of all mesothelioma patients in the United States were exposed to asbestos in the military.
  • Mesothelioma Facts
    Mesothelioma Facts
    Mesothelioma can be caused by laundering, or other household contact with, work clothing contaminated with asbestos.
  • Mesothelioma Facts
    Mesothelioma Facts
    Mesothelioma can be caused by work with (direct exposure) or around (bystander exposure) asbestos-containing products.
  • Mesothelioma Facts
    Mesothelioma Facts
    The average time between a person’s first exposure to asbestos and the development of mesothelioma (latency period) is more than 40 years.
 

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