Surgical Choices: Extra Pleural Pneumonectomy

Extra-pleural pneumonectomy (EPP) is a surgical procedure that involves the removal of the lung along with its coverings and the associated coverings of the heart, diaphragm and pericardium.

Steps in EPP Operative Technique for Malignant Pleural Mesothelioma

  1. Incision and exposure of parietal pleura

  2. Dissection of parietal pleura from endothoracic fascia, diaphragm, and mediastinum*

  3. Control and division of pulmonary vessels, subcarinal node dissection, staple main stem bronchus

  4. En bloc resection of lung, pleura, pericardium and diaphragm

  5. Reconstruction of diaphragm, pericardium **

* May need en bloc resection of diaphragm or pericardium
** In the right side

Additional Information


Surgery for Malignant Pleural Mesothelioma (6/2010)

Expert Review of Respiratory Medicine
The role of surgery for malignant pleural mesothelioma encompasses the need for rapid diagnosis, preoperative staging and surgical resection, and also the need for a greater biological understanding of this rare and aggressive malignancy. Pending the discovery of new drugs, the focus of clinical research over the next 5 years will emphasize refinements in patient selection, pathologic staging, molecular staging and other novel adjuvant therapies. More...


Second Surgery Efficacy for Recurrence of Malignant Pleural Mesothelioma after EPP (3/3/2010)

The second surgery did not offer the expected survival benefit of curative treatment strategies and should therefore be considered palliative. Second surgery may be a treatment option in a subset of patients who experience a solid recurrence of mesothelioma that is symptomatic or near vital organs and who cannot undergo additional radiotherapy. More...


Symptomatic and quality of life changes after extrapleural pneumonectomy for malignant pleural mesothelioma. (3/9/2009)

Extrapleural pneumonectomy (EPP) for malignant mesothelioma is considered an aggressive procedure, but symptomatic and quality of life changes are unknown. This study concludes that because EPP may rapidly improve symptoms it may also improve quality of life as well. More...


A possible association between aprotinin and improved survival after radical surgery for mesothelioma. (2/15/2009)

Aprotinin has been used to decrease blood loss with complicated cardiac surgery but has not been investigated in extrapleural pneumonectomy. More...  


Surgery and Mesothelioma: Why Operate? (10/08/08)

Review and discussion of “Macroscopic complete resection: The goal of primary surgery in multimodality therapy for pleural mesothelioma,” by David J. Sugarbaker, Journal of Thoracic Oncology, 2006

Few medical treatments make as much intuitive sense as surgery. When something inside is broken or diseased or useless, the right surgery can often repair it or remove it. Cancers can be especially susceptible to surgical cures, particularly when combined with chemotherapy and radiation. More...


Patient Reflections on EPP in 2007: A Conversation with June Breit (11/05/07)

June Breit is a 57 year-old mesothelioma survivor, clinical nurse, and patient advocate who lives in Phoenixville, Pennsylvania. She was diagnosed with malignant pleural mesothelioma, epithelioid type, in early 2002, and underwent an extra-pleural pneumonectomy at Brigham and Womens Hospital in Boston on June 26, 2002. She also had radiation and chemotherapy. June now has a recurrence of the tumor in her remaining lung, and is re-examining the role of the EPP in the arsenal of treatments for mesothelioma. More...

Updated December 26, 2007!!


Matrix of Care Part 1: Mesothelioma as a Family Illness (11/05/07)

A four-part series with Linda Reinstein, Executive Director of the Asbestos Disease Awareness Organization (ADAO). ADAO a registered nonprofit volunteer organization, united for united for asbestos disease awareness, education, advocacy, prevention, support and a cure. ADAO does not make legal or medical referrals. More...


Outcomes After Extrapleural Pneumonectomy and intensity-Modulated Radation Therapy for Malignant Pleural Mesothelioma (2007) Annals of Thoracic Surgery 2007

Although newer chemotherapeutic regimens have shown improved efficacy, median survival is generally only 9 to 12 months. Radiation as a primary treatment modality is limited because the extensive nature of the tumor requires large fields, and it is impossible to administer tumorcidal doses without injury to the underlying lung and adjacent organs. Extrapleural pneumonectomy (EPP), which includes en bloc resection of the lung, pleura, ipsilateral diaphragm, and pericardium, has shown modest efficacy, mainly in patients with early stage tumors of epithelioid histology More...


Prognostic Factors in the Treatment of Malignant Pleural Mesothelioma at a Large Tertiary Referral Center (10/07) J Thorac Oncol. 2007 Oct

Most studies describing the natural history and prognostic factors for malignant pleural mesothelioma antedate accurate pathologic diagnosis, staging by computed tomography, and a universal staging system. We conducted a large single-institution analysis to identify prognostic factors and assess the association of resection with outcome in a contemporary patient population. More...


Dr. Eric Vallières: Engaged on all Fronts. Seattle, Washington (10/22/07)

Whether he's expanding the minds of youngsters at Islander Middle School on Mercer Island, instructing eager surgical residents over the open chest of a cancer patient, leading a debate with thoracic surgeons over multi-modal treatment methods for mesothelioma, or chatting affably while reining in the 300-horsepower rumble of a ski boat, Dr. Eric Vallières is always fully engaged. More...


Extrapleural Pneumonectomy (EPP) for Malignant Pleural Mesothelioma, Results from Japan. (2/20/07)

The Department of Thoracic Surgery at Yokosuka Kyosai Hospital in Yokosuka, Japan analyzed 14 patients with malignant pleural mesothelioma (MPM) who underwent extrapleural pneumonectomy (EPP), a surgery that removes the entire affected lung. All patients were men and had an average age of 58.5 years. More...


Is Extrapleural Pneumonectomy the Preferred Surgical Management in the Multi Modal Treatment of Mesothelioma? Dr. Cameron weighs in against the EPP (Annals of Surgical Oncology, 2006) More...

  • No evidence the EPP is superior to lung-sparing P/D
  • Both surgeries carry potentially serious risks
  • Only experienced surgeons should attempt either surgery
  • "The EPP should not become the (Sir Edmund Hillary) operation of Thoracic Surgery: being done simply because it is there and because it can be done ks

Reported Efficacy of Radical EPP Surgery Questioned" Tom Treasure, MD, MS, FRCS; (October 6-7, 2006) (1/30/06)

Dr. Tom Treasure is a thoracic surgeon at Guy's Hospital in London, United Kingdom. At the 8th International Conference of the International Mesothelioma Interest Group (IMIG) held in Chicago, Illinois from October 19-22, 2006, Dr. Tom Treasure supported one side of a debate on the role of EPP for mesothelioma patients. More...


Extra-Pleural Pneumonectomy For Malignant Pleural Mesothelioma: the Risks of Induction Chemotherapy, Right-sided Procedures and Prolonged Operations (03/05) Eur J Cardiothorac Surg.

With the increasing incidence of malignant pleural mesothelioma and renewed interest in radical surgery as a therapeutic option, we have examined our experience of extra-pleural pneumonectomy, to document the incidence and management of its peri-operative complications. More...


R. McQuellon, et al, "Long-Term Survivorship and Quality of Life after Cytoreductive Surgery Plus Intraperitoneal Hyperthermic Chemotherapy for Peritoneal Carcinomatosis" Annals of Surgical Oncology, 10(2):155-162, 2003 (9/29/04

Conclusion: Long-term survival with good quality of life is possible for selected patients with peritoneal carcinomatosis after cytoredective surgery plus intraperitoneal hyperthermic chemotherapy. More...


Lancet Questions Merits of Radical EPP Surgery for MM (2004). Cardiothoracic Unit, Guy's Hospital, London SE1 9RT, UK (Prof T Treasure MD); and School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA (A Sedrakyan MD) (9/27/04)

Malignant mesothelioma has largely defeated treatment. Radical treatments, occupying the 3 months after diagnosis, can take up the best 3 months that the patient might have had. The evidence to date is that we might only be able to make small gains in symptom control and survival. The available evidence does not rule out the possibility that well-intentioned radical treatments do more harm than good. More...


David J. Sugarbaker, MD, et al, "Prevention, Early Detection, and Management of Complications After 328 Consecutive Extrapleural Pneumonectomies" J Thorac Cardiovasc Surg 2004; 128:138-1469 (6/30/04)

Conclusion: Complications after extrapleural pneumonectomy require a unique approach to management, and mortality can be minimized by early detection and aggressive treatment. More...


Valerie W. Rusch, MD, et al, "A Phase II Trial of Surgical Resection and Adjuvant High-dose Hemithoracic Radiation for Malignant Pleural Mesothelioma" J Thorac Cardiovasc Surg 2001;122:788-795 (Posted 5/21/04)

Conclusion: Hemithoracic radiation after complete surgical resection at a dose not previously reported is feasible. This approach dramatically reduces local recurrence and is associated with prolonged survival for early-stage tumors. Stage III disease has a high risk of early distant relapse and should be considered for trials of systemic therapy added to this regimen of resection and radiation. More...


Sean C. Grondin, MD, et al, "Pleuropneumonectomy in the Treatment of Malignant Pleural Mesothelioma" Chest. 1999;116:450S-454S (Posted 5/21/04)

Conclusions: With the development of multimodality therapy, pleuropneumonectomy followed by sequential chemotherapy and radiotherapy has demonstrated a significant survival benefit, especially for patients who have epithelial tumor histology, tumor-free resection margins, and tumor-free extrapleural node status. More...


British Editorial Radical Surgery for Mesothelioma (2/2/04)

One in every hundred men born in the 1940s will die of die of malignant pleural mesothelioma, which is almost exclusively a consequence of exposure to asbestos, with a lag time that is rarely less than 25 years and often more than 50 years from first exposure. Half of all cases are now aged over 70, with 80% in men. More...


Malignant Pleural Mesothelioma: Outcome of Limited Surgical Management (10/03) Department of Thoracic Medicine, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, UK

This study presents data on limited surgical management of malignant pleural mesothelioma. We reviewed retrospectively 70 cases of the disease managed surgically over a 10 year period. Fifteen patients received only diagnostic direct pleural biopsy, 40 had video-assisted thoracoscopic, pleural biopsy and talc pleurodesis while 15 patients underwent thoracotomy and pleurectomy for disease confined to the pleura. More...


British Editorial Randomized Controlled Trial Needed to Verify Whether Radical EPP Surgery Best Option for Mesothelioma (6/03)

Asbestos exposure in industry and construction sites in the 1960s and 1970s has left a legacy of mesothelioma, a diffuse pleural cancer, with a lag time of 40 to 50 years and due to peak around 2015 to 2020. Some surgeons believe that by radical surgery they can prolong life and relieve symptoms, but the evidence comes from very carefully selected series. How do surgeons respond to demand for evidence of benefit? More...


BWH to Broadcast EPP Surgery Over the Internet (4/30/03) ARCHIVE VERSION IS AVAILABLE


The Anatomy of an Extra Pleural Pneumonectomy (EPP) Broken Down, Step by Step. (3/14/03)