Extrapleural Pneumonectomy (EPP)

Who is Eligible For an EPP?

Patients are carefully evaluated under several criteria before they are considered for an EPP. Patients must be healthy enough not only to undergo the surgery, but also to undergo the extensive recovery process.

Under the standards of Brigham and Womenʼs Hospital, overall health and functionality is more important than age. Although a patient may not be able carry on with normal day-to-day activities without experiencing symptoms, they may still be eligible for surgery. The minimum requirement of patients to undergo this surgery is that they are still able to care for themselves.

Having healthy, normal heart function is also imperative as the heart and lungs work together to support the breathing process. Normal kidney and liver function is also required.

Patient Eligibility Tests

• Age and performance assessment
• Bloodchemistry
• Liver function tests
• Pulmonary function tests/quantitative ventilation-perfusion scan
• Echocardiogram and electrocardiogram
• CT-scan and MRI of chest
• Pleural biopsy

Diagnosis is also important in selecting patients for an EPP. This surgery is typically performed on patients in early stages of pleural mesothelioma. It is rare, though not unheard of, for patients diagnosed past stage 2 pleural mesothelioma to be admitted for an EPP.

The purpose of the surgery is to prevent the cancer from spreading. Therefore, if the cancer has already spread, the risks may outweigh the benefits of having the procedure. These requirements are important to protect ineligible patients from potentially fatal surgical complications.

Finding Surgical Treatment in VA Healthcare System

For patients seeking treatment through the VA, it is important to find a specialist in the VA healthcare system because general oncologists don’t have enough experience with mesothelioma to treat it effectively. Oftentimes, veterans are incorrectly told they aren’t eligible for procedures like the EPP because of their general oncologist’s lack of experience.

Some of the benefits of seeing a specialist through the VA may include:

• Access to specialized treatments, such as the extrapleural pneumonectomy, that may not be offered by general oncologists
• Financial assistance for travel and lodging
• Qualification for cost-free treatment or the option for private health insurance to reduce or eliminate copay

There are many general oncologists in the VA, but only two mesothelioma specialists. Additionally, only one uses the extrapleural pneumonectomy in his treatment plan—Dr. Avi Lebenthal at the Boston VA.

Veterans within the VA system can see Dr. Lebenthal if they are interested in the life-extending EPP. Dr. Lebenthal is a highly experienced mesothelioma specialist who also serves patients at the nearby Brigham and Women’s Hospital, which collaborates with the Boston VA in treating patients. Veterans getting treatment at the Boston VA get the same quality of treatment as patients in the top cancer centers in the country.

Surgical Procedure

The entire surgical process of an EPP is complex, but it can be summed up in 5 steps. This procedure has taken decades to develop and involves intricate steps to cauterize and redirect blood vessels to protect the patient from losing too much blood. It also takes expert surgical management to reduce trauma to the patient and decrease recovery time.

Before the procedure begins, the patient is placed under general anesthesia, and an endotracheal tube is inserted in the trachea. This allows the airway to the healthy lung to remain open, while simultaneously allowing the diseased lung to be collapsed. The time it takes to complete the procedure varies with each patient, but EPPs have been completed in as few as three hours.

5 Steps of an Extrapleural Pneumonectomy

• 1
  Incision–An incision is made to enter the chest cavity from the back to under the pectoral muscle. The sixth rib is removed to allow surgeons appropriate access.
• 2
  Extrapleural dissection–The pleura and pericardium are separated from the diaphragm and the chest wall.
• 3
  Division of pulmonary vessels–Blood vessels and arteries supplying the affected lung are severed and redirected.
• 4
  Removal of the affected areas–The lung, pleura, pericardium, part of the diaphragm and affected lymph nodes are removed.
• 5
  Reconstruction–The diaphragm and pericardium are reconstructed with Gore-Tex. (Gore-Tex is breathable, waterproof, and pliable.)

In cases where intraoperative therapy is used, heated, liquid chemotherapy is used to bathe the chest cavity after removal of the lung and before reconstruction.

This allows the highest concentration of chemotherapy possible to come into direct contact with the cancer cells. It also creates the ability to apply much higher dosages of chemotherapy without causing substantial side effects. The purpose of this added procedure is to attack any remaining microscopic mesothelioma cells left over in the chest cavity.

In addition, healthy cells are protected by injecting a cytoprotective agent into the patientʼs bloodstream prior to the intraoperative chemotherapy.

Recovering From EPP

The EPP has come a long way since its inception, and so has recovery. Continuing improvements in the way the procedure is conducted is making recovery more manageable for patients. One of the most recent methods making recovery easier is the introduction of robot-assisted EPP.

Regarding the patientʼs condition the day after surgery, Dr. Farid Gharagozloo said:

“Itʼs the difference between a patient on a ventilator and a patient who is sitting there reading a newspaper.”

Management of the procedure is only likely to get better, meaning recovery times should begin dramatically decreasing.

In-patient Recovery

Average hospital recovery time is about 2 weeks for patients who have undergone an EPP. These can be an intense two weeks. During this time the patient is already walking and doing light exercises to avoid post-surgery complications.

The patient is typically on a respirator for the first few days to help the healthy lung handle the burden of handling the entire breathing process. The hospital stay is required so the medical team can monitor the patientʼs recovery and spot any potential complications.

After surgery, the patient is monitored in a post-surgery care unit for several hours, or overnight in some cases, depending on the patientʼs overall health. Most patients experience common symptoms after surgery as well. Patients are likely to feel sleepy due to the anesthetic used in surgery, feel nauseated, and have a sore throat caused by the breathing tube used during surgery.

After Surgery Patients Are Monitored For:

• Blood pressure
• Pulse
• Temperature
• Breathing
• Oxygen level

First, the patient is only required to sit up and gently swing their legs off the side of their bed. The patient starts walking the halls (with a walker) as soon as the morning after surgery. The exercise is performed multiple times a day, increasing activity as the patient recovers.

Instruments to Help Patients Recover

• Chest tube (1-2 days): removes excess air and fluid from chest cavity
• Heart monitor (1-2 days)
• Catheter (1-4 days)
• IV for fluids and medicine (2-3 days)
• Arterial line (1-2 days): used for blood samples
• Oxygen mask or nasal prongs

Out-patient Recovery

Additional recovery at home lasts from six to eight weeks. During this time patients are advised not to exert themselves and get plenty of rest. Like any surgery, the body needs time adjust to the changes and new demands being made on it.

Breathing and walking exercises are resumed at home, and overall activity may be gradually increased. How quickly the patient can be active depends on how active the patient was prior to surgery and how good their overall health was.

Mike Dews was a patient of Dr. Sugarbaker. He had his surgery in 2001 and survived for an amazing 10 years after. Regarding his surgery he said:

“My recovery from the … surgery was difficult. Learning to breathe with one lung was difficult. But it did move along, and I was able to start walking. I was actually swinging the golf clubs within 100 days after my surgery.”

Mike Dewsʼ case is similar to many patients after they have an EPP. Golf becomes possible usually 4 months after surgery, and more demanding sports, like tennis and racquetball, are possible in 4-6 months. However, patients should consult with their doctor before beginning any laborious activities.

The recovery process can be difficult for many patients both physically and emotionally. They are forced to be less independent, relying on support systems for everyday functions. This, however, is only temporary. Recovery is more successful when patients are willing to accept help from family, friends and doctors.

Living Without a Lung

Something most patients always ask before having an EPP is, “what is it like to live without a lung?” Essentially, the organs on the side opposite that of the surgery shift to the empty space.

After the procedure is performed, the patient is left with an empty chest cavity. The cavity is generally filled with air. As noted before, there is a small tube in place to drain any fluid after surgery. However, the tube is removed after a few days. The empty cavity, then, gradually fills with fluid over a course of weeks to months.

Other Anatomical Changes

• Post-EPP space shrinks
• Diaphragm elevates
• Mediastinum (membranous division between the lungs) shifts to the post-EPP space
• Hyperinflation of remaining lung
• Remaining lung begins shifting to post-EPP space
• Heart shifts towards post-EPP space

Risks Associated with Surgery

The first EPPs conducted for mesothelioma, like other trials during early experimental phases, had a rather high mortality rate. During the 1970ʼs the mortality rate was around 30%. However, the rates have significantly decreased since then, hovering between 8% and 15%. Non-fatal complications may also arise during surgery.

Typical EPP Risks

• Internal bleeding
• Respiratory failure
• Pneumonia
• Infection
• Blood clots
• Pulmonary edema

Risks are inherent with any major surgery. Unsurprisingly, cancer centers that experience a high volume of mesothelioma cases are more likely to have a much lower mortality rate than the reported average.

The thoracic surgery team here has achieved unprecedented results in lowering the mortality rate associated with surgery and increasing the life expectancy of patients undergoing the surgery.

Key Benefits of EPP

The EPP is considered by most to have the best potential to treat pleural mesothelioma. It has produced outstanding results in improving breathing quality and life expectancy. Without receiving any treatment, the average life expectancy for pleural mesothelioma patients is 4 to 12 months.

A study led by Dr. Sugarbaker showed a median survival time of 19 months after an EPP. Some of the patients in this study even survived several years past their original prognosis.

Stage 1 patients who had an epithelioid cell type in the study had an especially optimistic outlook with an impressive 51-month median survival time.

The benefits of having an EPP are obvious. This is a surgery where the goal is to treat the patient by eradicating as much of the tumor as possible. This procedure is responsible for an improved quality of life for many patients. Of course, any radical surgical procedure isn’t going to be without its critics. This is why patients should always seek an experienced mesothelioma specialist.

Ongoing Debate

There are many critics of the EPP. Many believe the procedure is too aggressive and has an unacceptable mortality rate. Brigham and Womensʼ 3.4% mortality rate involving EPPʼs is an exception due to years of research and a high volume of cases.

The alternative to receiving an EPP is the pleurectomy/decortication (P/D), which doesnʼt involve the removal of the lung or diaphragm. Critics of the EPP tend to support the P/D because they believe the quality of life for a patient receiving this procedure is better than that of a patient receiving an EPP.

The pleurectomy/decortication has also had traditionally lower mortality rates than the EPP, though it is not as effective for treating patients past stage 2. Studies have shown survival rates to be relatively the same among both of the procedures, but P/D critics argue the EPP has a better chance of removing all of the cancerous tissue.

Patients should seek second opinions from mesothelioma specialists if they are considering radical surgery like EPP. Each patientʼs unique diagnosis is going to play a significant role determining what they can endure, surgically speaking, as well as which option gives them the best chance at a better quality of life.

Find a mesothelioma specialist to get the right treatment for you.