What Is an Extrapleural Pneumonectomy (EPP)?

Understanding EPP Surgery

Extrapleural pneumonectomy (EPP) is one of the most extensive surgical procedures for malignant pleural mesothelioma. The operation involves en bloc removal of the entire affected lung, the visceral and parietal pleura, the ipsilateral diaphragm, and the ipsilateral pericardium. The diaphragm and pericardium are then reconstructed using prosthetic patches. The goal is to achieve macroscopic complete resection — removing all visible tumor from the chest cavity.

EPP was pioneered in the 1970s and refined over subsequent decades. It remains a viable option for carefully selected patients, though its use has become more debated as pleurectomy/decortication (P/D) has gained favor at many institutions due to its lung-sparing approach and potentially lower perioperative mortality.

Who Qualifies for EPP?

EPP is reserved for patients who meet strict eligibility criteria. Ideal candidates typically have stage I or II pleural mesothelioma with epithelioid cell type, adequate pulmonary function to sustain life with a single lung, good cardiac function, and an overall performance status that can tolerate a major operation and recovery.

Patients with sarcomatoid or biphasic mesothelioma, advanced-stage disease, or significant comorbidities are generally not considered for EPP. A thorough multidisciplinary evaluation at a specialized mesothelioma treatment center is essential before proceeding.

The EPP Procedure

EPP is performed under general anesthesia and typically requires 6–8 hours. The surgeon begins with an extended posterolateral thoracotomy incision to access the chest cavity. The lung, pleural membranes, hemidiaphragm, and pericardium are carefully dissected and removed together. Lymph nodes are sampled or removed for examination.

After tumor removal, the surgeon reconstructs the diaphragm and pericardium using Gore-Tex or similar prosthetic material. Chest tubes are placed for drainage, and patients are transferred to the intensive care unit for monitoring.

Recovery and Risks

Most patients spend 7–14 days in the hospital after EPP, with 1–3 days in the ICU. Full recovery typically takes 6–8 weeks, during which patients gradually rebuild exercise tolerance with one lung. Breathing exercises and pulmonary rehabilitation are standard postoperative care.

EPP carries significant risks, including a perioperative mortality rate of 3–7% at experienced centers. Potential complications include cardiac arrhythmias, pneumonia, bronchopleural fistula, and deep vein thrombosis. These risks underscore the importance of having EPP performed by a highly experienced mesothelioma surgeon.

Survival and Financial Considerations

When performed as part of a multimodal plan that includes chemotherapy and/or radiation, EPP has been associated with median survival of 12–22 months. Patients with epithelioid cell type and negative surgical margins tend to have the best outcomes, with some long-term survivors exceeding five years.

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