Extrapleural Pneumonectomy Versus Pleurectomy

Introduction

Pleural mesothelioma, also known as malignant pleural mesothelioma, is a rare cancer that develops in the lining of the chest and lung walls. People with this cancer might have either extrapleural pneumonectomy or pleurectomy/decortication (P/D) to try and live longer. The main cause of pleural mesotheliom is asbestos exposure, a mineral that was once commonly used in construction and manufacturing. Over time, the inhaled asbestos fibers can lead to the formation of cancerous cells in the pleura.

What Is Extrapleural Pneumonectomy?

Extrapleural pneumonectomy (EPP) is a surgery used to treat pleural mesothelioma, a type of cancer affecting the lining of the lungs. During EPP, doctors remove the diseased lung, part or all of the diaphragm (the muscle separating the chest and abdomen), a portion of the membrane covering the heart (pericardium), and a section of the membrane that covers the chest cavity (parietal pleura). The primary objective of this surgical procedure is to eliminate all detectable cancer cells, which could potentially improve the patient's chances of survival. EPP is often combined with other treatments like chemotherapy and radiation, either before or after the surgery.

What Is Pleurectomy?

A pleurectomy is a surgery to remove part or all of the pleura, which is a membrane covering the lungs and chest. This procedure is done to treat infections like empyema and other lung issues. The pleural cavity is the space between the outer and inner layers of the pleura.

In a pleurectomy, either the outer or inner pleura is removed. In a more extensive procedure called pleurectomy/decortication (P/D), both layers are removed, along with any tumors or fibrous tissue. Surgeons may remove the inner or outer pleura, or both, depending on the specific situation.

Pleurectomy can serve different purposes, such as:

• Relieving Symptoms: It helps by getting rid of fluid buildup in the pleural cavity, which can ease symptoms of certain conditions.

• Diagnosing Conditions: Surgeons can take biopsies during the procedure to diagnose specific conditions.

• Treating Cancers: In cases like mesothelioma, tumors can be removed through a more comprehensive pleurectomy/decortication (P/D) surgery.

Pleurectomy/decortication (P/D) is sometimes called a lung-sparing surgery because it removes the cancerous tissue covering a lung but not the whole lung itself. It is a less aggressive approach compared to EPP. In some cases, P/D may also include taking out a part of the diaphragm and/or a section of the heart lining (pericardium). When these parts are involved, the procedure is called an extended P/D.

Who Qualifies for Extrapleural Pneumonectomy?

• Not all pleural mesothelioma patients qualify for extrapleural pneumonectomy (EPP) surgery.

• Candidates for EPP need to be in good overall health due to the aggressive nature of the procedure.

• Doctors assess the extent of tumors, especially if they are widespread in the lung or present on the diaphragm or pericardium.

• Predicted lung function after surgery is considered to determine eligibility for EPP.

• Patients with sarcomatoid mesothelioma or less than 30 percent predicted lung function are usually not eligible for EPP.

• Patients ineligible for EPP may still be candidates for pleurectomy/decortication or other alternative therapies.

• Eligibility for EPP and other treatments should be discussed with a doctor based on individual health conditions and tumor characteristics.

Who Qualifies for Pleurectomy?

• Not everyone can have a pleurectomy.

• People eligible for this procedure must be in good health and should not smoke. If they do smoke, they must quit before the surgery.

• The eligibility also depends on the reason for the pleurectomy. If it is to treat mesothelioma, the cancer should not have spread extensively outside the lungs. If it has, the surgery might not be able to remove all cancer cells, making the risks greater than the benefits.

What Are the Risks and Complications of Extrapleural Pneumonectomy?

Extrapleural pneumonectomy (EPP) is a surgery that carries certain risks and complications, just like any other surgical procedure. These complications can happen shortly after the surgery or in the long run. The severity of these complications varies from person to person.

Short-Term and Long-Term Complications:

• Arrhythmia: Irregular heartbeat.

• Blood Clots: Clumps of blood that can cause blockages.

• Bronchopleural Fistula: Abnormal connection between lung airways and pleura.

• Fluid Buildup in Lungs: Accumulation of fluids in the lung space.

• Infection: Presence of harmful bacteria causing illness.

• Internal Bleeding: Bleeding inside the body.

• Pneumonia: Inflammation in the lungs.

• Pus Accumulation: Buildup of infected fluid in the pleural space.

• Shortness of Breath: Difficulty in breathing.

What Are the Risks and Complications of Pleurectomy?

• Anesthesia Complications: Problems related to anesthesia, like breathing difficulties or allergic reactions.

• Infection: Risk of harmful bacteria causing illness after the surgery.

• Bleeding: Possibility of internal bleeding during or after the procedure.

• Lung Complications: Issues concerning the lungs after surgery.

• Chest Discomfort: Pain or discomfort in the chest area after the procedure.

• Swelling: Swelling in the lung or chest area where the surgery was done.

• Breathing Difficulty: Difficulty in breathing due to reduced lung capacity.

• Pain Management: Doctors may prescribe pain medication to manage discomfort after surgery.

• Temporary Discomfort: Most postoperative pain and discomfort usually decrease over time.

What Are the Differences Between Extrapleural Pneumonectomy and Pleurectomy?

1. Purpose of Surgery:

• P/D: Removes the lining of the lung and nearby tissues while preserving the lung. It relieves symptoms, improves survival, and treats localized mesothelioma, which is especially effective in the early stages.

• EPP: Removes the entire lung along with surrounding tissues. Targets more advanced mesothelioma cases but significantly impacts the patient’s quality of life.

2. Surgical Techniques and Invasiveness:

• P/D: Less invasive procedure involves removing specific tissues. Preserves lung integrity, leading to a better post-surgery quality of life.

• EPP: More invasive, necessitates the removal of the entire lung and adjacent tissues. Significantly affects the patient's stamina and daily activities due to the loss of a lung.

3. Impact on Patients:

• P/D:Lower Mortality Rate: Approximately one to two percent of patients experience mortality during or after the surgery. Possible complications include prolonged air leaks in the chest, which are manageable.

• EPP:Higher Mortality Rate: Approximately four to five percent of patients face mortality during or after the surgery. More severe complications may be experienced, like abnormal heart rates or arterial blockages, posing greater risks.

4. Survivorship and Quality of Life:

• Studies show a median overall survival of 22 months for P/D patients compared to 15 months for EPP patients. Survivorship is influenced by several factors like cancer stage, cell type, patient’s age, and adjuvant therapies, in addition to the surgical choice.

• P/D: Maintains both lungs, preserving stamina and overall quality of life.

• EPP: Removing an entire lung permanently reduces the patient's stamina and daily capabilities.

Conclusion

In treating pleural mesothelioma, patients and doctors need to think carefully about the type of surgery to choose. Some surgeries are less invasive, while others are more aggressive. The decision should consider how advanced the cancer is and the patient's overall health. It is essential to talk openly with healthcare providers to make the best choice for the patient's well-being and quality of life.