Extrapleural pneumonectomy

Malignant pleural mesothelioma (MPM) is an increasing tumor of the pleura due to asbestos exposure. Its prognosis is poor if not treated. Chemotherapy and radiotherapy alone give a dismal survival. Surgery remains the main treatment allowing good long-term outcomes. Two operations have been developed in this context: extrapleural pneumonectomy (EPP), which involved the en bloc resection of the lung, parietal and visceral pleurae, diaphragm, and pericardium; and radical or extended pleurectomy/decortication (P/D), which include removal of the parietal and visceral pleurae, including resection of the diaphragm and/or pericardium if involved by tumor, but always preservation of the underlying lung. Preoperative assessment of patients who should receive EPP tumor extension is paramount. Radiological exams include chest and abdominal computed tomography (CT), positron emission tomography, and, in some cases, magnetic resonance imaging of the chest. Respiratory and cardiological assessment is also very important to evaluate if the patient is fit to receive EPP. We herein describe the technical aspects of EPP reporting the set of steps to perform this important surgical procedure underlining tips and tricks.