EPP vs P/D

If you have been diagnosed with mesothelioma, you may be eligible for one of two potentially life-extending surgeries: extrapleural pneumonectomy (removal of the lung and diseased chest cavity tissue) or pleurectomy with decortication (a lung-sparing procedure with removal of tumors and diseased tissue).

EPP vs P/D Overview

Surgery is a significant part of mesothelioma treatment plans. Both extrapleural pneumonectomy (EPP) and pleurectomy with decortication (P/D) are best suited to patients with stage 1 or 2 pleural mesothelioma. The main goal of these curative procedures is to remove mesothelioma from the chest cavity before it has metastasized (spread to distant sites) and to prevent recurrence (when the mesothelioma comes back after being removed).

Patients with late-stage mesothelioma may be eligible for palliative surgeries with either the EPP or P/D. The goal in these cases is to relieve difficult symptoms such as trouble breathing and to improve quality of life. Whether undergoing curative or palliative mesothelioma surgery, patients must be in good overall health to withstand the operation.

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Video Summary: Registered Nurse Amy Fair discusses mesothelioma surgery options and who may be a candidate. View Transcript.

What are the surgical treatment options for mesothelioma?

It’s important to talk to your surgeon and oncologist to see if you are a surgical candidate. Some folks that have extensive disease (cancer) are not a surgical candidate and they will start with other treatment modalities such as radiation and chemotherapy. With comorbidities such as diabetes, heart, and some lung conditions the surgeon may tell you you’re not a surgical candidate. Sometimes the cell type of your disease and the staging also drives if you are a surgical candidate or not for surgery.

Some of the surgeries performed for mesothelioma are a decortication, which is where they remove the lining of the lung, sometimes called a pleurectomy. There is a more extensive surgery called a pneumonectomy. That is where they remove the whole lung. There are surgical interventions for the peritoneal mesothelioma. Sometimes they will go in and do a recession of the damaged or diseased part of the intestines. There is a procedure called a HIPEC procedure where they go into the abdomen and they flood the abdomen with what is called a chemo wash. It is a more direct line and source of chemotherapy than the intravenous route.

Your surgeon will explain to you all the components of the surgery, pre-surgery, and post-surgery. They will tell you that you may have a chest tube. Many times, surgeries, decortications, things like that will cause the lung to collapse. That’s very normal so they will tell you that you may have a chest tube in place to inflate or to keep that lung from collapsing. Post-surgery it’s all about the healing phase. It’s about pain control. It’s about getting up and keeping your pneumonias down, getting up and being active. Post-surgery sometimes the patient is sent home with a catheter in their pleura called a pleura evac, pleura catheter where it continues to drain the fluid once the patient is at home. They will talk with them about good nutrition. They will talk with them about keeping their immune system strong so the healing process proceeded like it should.

EPP involves resection of the affected lung, along with the pleura (lung lining), pericardium (heart lining), part of the diaphragm, and nearby lymph nodes. Recovery is extensive, with up to two weeks spent in the hospital followed by an additional three months’ recovery at home.

P/D is a two-part operation that spares the affected lung. Instead, the surgeon removes the lung lining during pleurectomy (and in some cases nearby chest cavity tissue) and visible tumors during decortication. Recovery is one week in the hospital and an additional one month at home.

Choosing between EPP and P/D is an important decision that you should make in consultation with a mesothelioma specialist.

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EPP vs P/D Procedure

Both EPP and P/D are major, open surgeries performed by only the top thoracic surgeons at large medical centers. Patients should understand how the two procedures differ before, during, and after the operation.

Extrapleural Pneumonectomy Procedure

  • Operation time: Approximately three hours
  • In-hospital recovery: Up to two weeks
  • At-home recovery: Approximately three months

Before surgery, doctors run a variety of tests to ensure you are healthy enough to undergo the operation. It is especially crucial that your lung function is adequate for you to live with a single lung and breathe without assistance. For curative EPP, doctors will also scan your chest cavity to confirm that the cancer has not metastasized to other areas.

EPP is performed under general anesthesia. The surgeon makes an incision along the front or side of your chest to enter the lung space. The surgeon then removes the affected lung, along with the pleura, pericardium, part of the diaphragm and nearby lymph nodes.

Recovery is extensive, and patients can expect to stay in the hospital for up to two weeks. Further recovery time at home is approximately three months, and doctors will prescribe a combination of rest and rehabilitation during this time.

Pleurectomy with Decortication Procedure

  • Operation time: Approximately five hours
  • In-hospital recovery: Up to one week
  • At-home recovery: Approximately one month

As with EPP, patients must be in good general health to undergo pleurectomy with decortication. Doctors will measure overall health and fitness, while also confirming tumor locations ahead of the decortication process.

P/D is performed under general anesthesia. The surgeon makes an incision along your back and side to enter the chest cavity; other incisions may be necessary if additional access points are required to remove tumors.

The surgeon first removes the pleura and possibly the pericardium, part of the diaphragm, and other diseased chest cavity tissue. In the decortication stage, the surgeon removes visible tumors and may use a variety of techniques to eliminate unseen mesothelioma.

Patients can expect to remain in the hospital for one week after surgery. At-home recovery time is approximately one month, after which point patients are often able to resume most activities — while being careful of over-exertion.

EPP vs P/D Goals and Benefits

When performed on the right candidates, both surgeries offer the potential to extend life expectancy and relieve painful symptoms. The goals and benefits vary for each, depending on the mesothelioma stage and other factors.

Extrapleural Pneumonectomy Goals

The goal for curative EPP is to remove as much cancer as possible to reduce the probability of metastasis and recurrence. While EPP is considered radical for resecting the entire lung, the recurrence rate after surgery is the lowest of the two procedures at 33%.

Palliative EPP may be an option for patients with late-stage mesothelioma. These patients benefit from relief of chest pain, shortness of breath, and coughing. EPP in these cases is not curative, but some studies suggest palliative treatment helps to extend life expectancy.

Pleurectomy with Decortication Goals

For curative P/D surgery, the main goal is to eliminate mesothelioma before it metastasizes. The 65% recurrence rate after P/D is higher than after EPP, but sparing the lung may be optimal for some patients.

Patients with late-stage mesothelioma who are in good general health may be eligible for palliative P/D. Removing tumor masses from the lung space eases difficulty breathing immediately after the operation and enhances the overall quality of life.

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EPP vs P/D Life Expectancy

  • Extrapleural pneumonectomy life expectancy: 10 to 35 months
  • Pleurectomy with decortication life expectancy: 8 to 22 months

Life expectancy refers to the average time patients can expect to live following surgery. These statistics suggest EPP provides a longer life expectancy than P/D, but it is important to note that survival statistics are unique to each patient and the individual factors involved.

Patients who undergo either procedure can extend their life expectancy further by combining surgery with other treatments in a multimodal approach. Your mesothelioma specialist may recommend a combination of chemotherapy, radiation, alternative treatments (such as special diets or exercise regimens), or clinical trials.

EPP vs P/D Morbidity Rates

  • Extrapleural pneumonectomy morbidity rate: 2–7%
  • Pleurectomy with decortication morbidity rate: 1–5%

Morbidity rate refers to the percentage of patients who die during or shortly after the operation. Risk factors including the patient’s age, gender, mesothelioma stage, other medical conditions, and overall health all affect the probability of complications associated with surgery.

Operating on and near vital organs always carries a risk of complication. However, new research and medical advances continue to lower the morbidity rate of both surgeries, as well as the probability of non-lethal complications.

Choosing Between EPP and P/D

Medical professionals disagree about which mesothelioma surgery is most effective. Some doctors believe that despite the removal of the entire lung, the lower recurrence rate after EPP offers patients the best prognosis. Other doctors think the lung-saving P/D is the better option.

There are many facts to consider when choosing between EPP and P/D surgery. Contact a Mesothelioma Hope Patient Advocate today to help you digest the information and determine a treatment plan tailored to your unique case.

Mesothelioma Support Team

Mesothelioma Hope was founded by a team of advocates to educate people about this aggressive form of cancer. Mesothelioma affects thousands of people each year. We help give hope to those impacted by mesothelioma.

View 3 References
  1. General Thoracic and Cardiovascular Surgery, “Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma.” Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153961/. Accessed on February 11, 2018.
  2. Medscape, “Surgery for Malignant Pleural Mesothelioma.” Retrieved from: https://www.medscape.com/viewarticle/724140. Accessed on February 11, 2018.
  3. Pacific Heart, Lung & Blood Institute, “Lung-Saving PD vs. Radical EPP.” Retrieved from http://www.phlbi.org/sfor-patients/lung-saving-pd-vs-radical-epp/. Accessed on Feb. 11, 2018.

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