View source for Extrapleural Pneumonectomy

{{#seo:
|title=Extrapleural Pneumonectomy (EPP): Surgical Technique, Outcomes, Complications & the EPP vs P/D Debate
|description=Comprehensive reference on extrapleural pneumonectomy for malignant pleural mesothelioma. Covers surgical technique, survival data by subgroup, the Sugarbaker favorable triad, MARS trial results, complications, quality of life, multimodal protocols, recurrence patterns, cost data, and current guideline positions.
|keywords=extrapleural pneumonectomy, EPP mesothelioma, EPP surgery, EPP vs P/D, mesothelioma surgery, Sugarbaker EPP, MARS trial mesothelioma, trimodal therapy mesothelioma, EPP survival rates, EPP complications, SMART protocol mesothelioma
|author=David Foster, Patient Advocate, Danziger & De Llano
|published_time=2026-03-03
}}
{| class="infobox" style="width:300px; float:right; margin:0 0 1em 1em; border:2px solid #1a5276; border-radius:8px; overflow:hidden;"
|-
! colspan="2" style="background:#1a5276; color:white; padding:12px; font-size:1.1em; text-align:center;" | Extrapleural Pneumonectomy
|-
| colspan="2" style="padding:10px; text-align:center; font-style:italic; border-bottom:1px solid #dee2e6;" | Radical Surgical Resection for Malignant Pleural Mesothelioma
|-
| style="padding:10px; font-weight:bold; width:40%; border-bottom:1px solid #dee2e6;" | Procedure Type
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Radical Surgical Resection
|-
| style="padding:10px; font-weight:bold; border-bottom:1px solid #dee2e6;" | Structures Removed
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Lung, pleura, pericardium, diaphragm
|-
| style="padding:10px; font-weight:bold; border-bottom:1px solid #dee2e6;" | First Described
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 1949 (Sarot)
|-
| style="padding:10px; font-weight:bold; border-bottom:1px solid #dee2e6;" | First for Mesothelioma
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 1976 (Butchart)
|-
| style="padding:10px; font-weight:bold; border-bottom:1px solid #dee2e6;" | Operative Mortality
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''3.8–7%'''
|-
| style="padding:10px; font-weight:bold; border-bottom:1px solid #dee2e6;" | Median Survival
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 14–19 months (all comers)
|-
| style="padding:10px; font-weight:bold; border-bottom:1px solid #dee2e6;" | Best Subgroup Survival
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''46% at 5 years''' (favorable triad)
|-
| style="padding:10px; font-weight:bold; border-bottom:1px solid #dee2e6;" | Hospital Stay
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 10–11 days (median)
|-
| style="padding:10px; font-weight:bold;" | Current Status
| style="padding:10px;" | Limited use; [[Pleurectomy and Decortication|P/D]] preferred
|-
| colspan="2" style="background:#1a5276; padding:10px; text-align:center;" | <span data-nosnippet class="noai-content">[https://dandell.com/contact-us/ <span style="color:white; font-weight:bold;">Free Case Review →</span>]</span>
|}

= Extrapleural Pneumonectomy: The Most Radical Surgical Treatment for Pleural Mesothelioma =

== Executive Summary ==

Extrapleural pneumonectomy (EPP) is the most radical surgical procedure used in the treatment of [[Understanding Your Diagnosis|malignant pleural mesothelioma]] (MPM), involving the en bloc removal of the affected lung, visceral and parietal pleura, ipsilateral pericardium, and ipsilateral hemidiaphragm.<ref name="pmc_epp" /><ref name="dandell_surgery" /> First described by Sarot in 1949 for tuberculous empyema and later applied to mesothelioma by Butchart and colleagues in 1976, EPP was once the cornerstone of aggressive multimodal mesothelioma treatment.<ref name="sugarbaker_99" />

The procedure gained prominence through the work of Dr. David Sugarbaker at Brigham and Women's Hospital, whose 1999 landmark series of 183 patients demonstrated 3.8% perioperative mortality and, in a carefully selected subgroup with epithelioid histology, negative nodes, and complete resection margins, a remarkable 46% five-year survival rate.<ref name="sugarbaker_99" /><ref name="mlc_treatment" /> However, the trajectory of EPP changed dramatically following the MARS trial in 2011, which found worse survival in the EPP group compared to no surgery, and the MARS 2 trial in 2024, which showed that even the less radical [[Pleurectomy and Decortication|pleurectomy/decortication (P/D)]] did not improve survival over chemotherapy alone.<ref name="mars_11" /><ref name="mars2_24" />

Current guidelines from the NCCN, BTS, and ASCO now recommend P/D over EPP, with EPP reserved for highly selected patients at specialized centers of excellence.<ref name="asco_25" /><ref name="bts_18" /> For mesothelioma patients and their families evaluating surgical options, understanding the risks, benefits, and evolving evidence surrounding EPP is critical to making informed treatment decisions.<ref name="dandell_treatment" /><ref name="mesonet_treatment" />

'''Extrapleural pneumonectomy at a glance:'''

* '''EPP removes the entire lung vs. P/D which preserves it''' — patients undergoing EPP lose all ipsilateral pulmonary function permanently, while P/D patients retain 65% of predicted FEV1 postoperatively<ref name="qol_zurich" /><ref name="pmc_epp" />
* '''Operative mortality is 2.5 times higher with EPP than P/D''' — 4.5% vs. 1.7% across 2,903 patients in the largest meta-analysis comparing the two procedures<ref name="taioli_15" />
* '''Overall morbidity after EPP is more than double that of P/D''' — 62% of EPP patients experience major complications vs. 27.9% for P/D<ref name="batirel" />
* '''Carefully selected EPP patients survive 3 times longer than unselected cases''' — the Sugarbaker favorable triad achieved 51 months median survival vs. 14–19 months for all-comers<ref name="sugarbaker_99" />
* '''EPP achieves better local control but worse distant control than P/D''' — local recurrence is 33% after EPP vs. 65% after P/D, but distant recurrence is 66% vs. 35%<ref name="flores_08" />
* '''SMART protocol EPP patients survived 4 times longer than standard EPP patients''' — 65.9 months median survival in the epithelioid node-negative SMART subgroup vs. 14–19 months in conventional series<ref name="smart_21" />
* '''Post-EPP lung function drops nearly twice as much as after P/D''' — FEV1 declines from 76% to 48% predicted after EPP vs. 82% to 65% after P/D<ref name="qol_zurich" />
* '''EPP costs 16% more than P/D per hospitalization''' — mean hospital cost of $62,408 for EPP vs. $53,993 for P/D based on national inpatient data<ref name="costs_19" />
* '''Only 11% of mesothelioma surgery patients now receive EPP vs. 57% receiving P/D''' — reflecting a decisive shift toward lung-sparing approaches across major guidelines<ref name="asco_25" /><ref name="bts_18" />
* '''Patients treated at high-volume centers have 20–40% better survival than those at general hospitals''' — surgical volume is one of the strongest predictors of EPP outcomes<ref name="mlnm_centers" />

== Key Facts ==

{| class="wikitable" style="width:100%; margin:1em 0; border-collapse:collapse;"
|-
! style="background:#1a5276; color:white; padding:10px;" | Metric
! style="background:#1a5276; color:white; padding:10px;" | Finding
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Procedure scope'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | En bloc resection of lung, pleura, pericardium, and diaphragm
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Operative mortality (Sugarbaker 1999, n=183)'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 3.8% (30-day); up to 7% in multi-institutional registries (Flores 2008, n=385)<ref name="sugarbaker_99" /><ref name="flores_08" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Overall median survival'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 14–19 months (all comers); 18 months in 529-patient series (Sugarbaker 2014)<ref name="sugarbaker_14" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Favorable triad survival (Sugarbaker 1999, n=31)'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Epithelioid + negative nodes + negative margins = 46% five-year survival (median 51 months)<ref name="sugarbaker_99" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''MARS trial result (2011, n=50)'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | EPP 14.4 months vs. no surgery 19.5 months; HR 2.75 (95% CI 0.91–8.27; p=0.07)<ref name="mars_11" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''EPP vs. P/D mortality (Taioli 2015, n=2,903)'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 30-day mortality: EPP 4.5% vs. P/D 1.7%<ref name="taioli_15" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Major complication rate (Batirel systematic review)'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | EPP 62.0% overall morbidity vs. P/D 27.9%<ref name="batirel" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Most common complication (Sugarbaker 2004, n=328)'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Atrial fibrillation in 44.2% of EPP patients<ref name="sugarbaker_04" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Hospital cost (2014 NIS data)'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Mean $62,408 (95% CI: $48,385–$76,431); median stay 10–11 days<ref name="costs_19" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''SMART protocol result (de Perrot 2021, n=96)'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 30-day mortality 1%; epithelioid N0 subgroup median 65.9 months<ref name="smart_21" />
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''Recurrence patterns (Baldini 2015, n=169)'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 75% overall recurrence at median 13.1 months; local 54%, abdominal 39%<ref name="baldini_15" />
|-
| style="padding:10px;" | '''Guideline consensus (NCCN 2025, BTS 2018, ASCO 2025)'''
| style="padding:10px;" | P/D preferred over EPP; BTS explicitly recommends against EPP; EPP reserved for centers of excellence<ref name="asco_25" /><ref name="bts_18" />
|}

== What Is Extrapleural Pneumonectomy? ==

Extrapleural pneumonectomy is defined as the en bloc surgical removal of the ipsilateral lung together with the visceral and parietal pleura, ipsilateral pericardium, and ipsilateral hemidiaphragm for the treatment of malignant pleural mesothelioma.<ref name="pmc_epp" /><ref name="mlc_surgery" /> The procedure represents the most aggressive surgical approach to mesothelioma, designed to achieve macroscopic complete resection (MCR) of all visible tumor by removing every pleural surface and the organs they encase.<ref name="dandell_surgery" />

The term ''extrapleural'' refers to the surgical plane of dissection, which lies outside the parietal pleura. This distinguishes EPP from standard pneumonectomy (lung removal alone) and from [[Pleurectomy and Decortication|pleurectomy/decortication]] (P/D), which removes the pleura but preserves the lung.<ref name="pmc_epp" /> Radical mediastinal lymph node dissection is performed concurrently to assess nodal disease, which is one of the strongest prognostic factors determining survival after EPP.<ref name="sugarbaker_14" />

EPP is never performed in isolation. It is always part of a multimodal treatment strategy that typically combines surgery with chemotherapy (usually cisplatin and pemetrexed) and, in some protocols, hemithoracic radiation therapy.<ref name="mesonet_treatment" /><ref name="sugarbaker_99" /> The rationale for combining these modalities is that surgery addresses local disease while chemotherapy and radiation target microscopic residual cancer cells that cannot be removed surgically.

== How Is EPP Performed? ==

The EPP procedure is performed through an extended posterolateral thoracotomy, with the incision beginning midway between the posterior scapular tip and the spine and extending along the sixth rib to the costochondral junction.<ref name="pmc_epp" /> The latissimus dorsi and serratus anterior muscles are divided, and the sixth rib is typically resected to provide adequate surgical exposure. The posterior periosteum in the bed of the sixth rib is incised to expose the extrapleural plane.

The surgical sequence proceeds as follows:<ref name="pmc_epp" /><ref name="dandell_surgery" />

# '''Incision and exposure''' of the parietal pleura via posterolateral thoracotomy
# '''Extrapleural dissection''' using combined sharp and blunt technique, separating tumor-bearing pleura from the chest wall, continuing to the apex, mediastinum, esophagus, and great vessels
# '''En bloc resection''' of the lung, pleura, pericardium, and diaphragm with division of the hilar structures (pulmonary artery, pulmonary veins, and mainstem bronchus)
# '''Radical lymph node dissection''' of mediastinal lymph node stations
# '''Reconstruction''' of the diaphragm and pericardium with synthetic patches

The diaphragm and pericardium are reconstructed using Gore-Tex (PTFE) patches. Routine pericardial reconstruction has been shown to reduce the incidence of cardiac herniation, a potentially fatal complication.<ref name="pmc_recon" /> Published data on operative duration are limited, with informal estimates citing 6 to 10 hours for the complete procedure. The literature distinguishes standard EPP from ''extended EPP'', which involves additional resection of chest wall structures, great vessels, or esophageal muscularis beyond the standard specimen.<ref name="pmc_epp" />

== Who Is a Candidate for EPP? ==

Patient selection is the single most important factor determining outcomes after EPP. Current practice restricts EPP candidacy to a narrow subset of mesothelioma patients meeting stringent clinical criteria.<ref name="asco_25" /><ref name="dandell_treatment" />

=== Staging Requirements ===

EPP candidates must have clinical early-stage disease, typically '''T1 to T3, N0''' (no lymph node involvement). N2 mediastinal nodal disease is a major adverse prognostic factor. In the Sugarbaker 529-patient series, patients with N2 disease had a median survival of only 13 months compared to 26 months for N0 patients, leading many centers to consider N2 involvement a contraindication to EPP.<ref name="sugarbaker_14" /> Preoperative mediastinal staging with mediastinoscopy or endobronchial ultrasound is recommended to exclude N2 disease before proceeding.<ref name="ers_20" />

=== Histological Requirements ===

'''Epithelioid''' histology is the only subtype routinely considered for EPP.<ref name="sugarbaker_99" /> Biphasic mesothelioma carries a significantly worse prognosis and is approached with caution at most centers. '''Sarcomatoid''' histology is generally excluded from curative-intent surgery, including EPP, due to its aggressive biology and uniformly poor surgical outcomes.<ref name="mlc_treatment" /><ref name="mesonet" />

=== Cardiopulmonary and Performance Requirements ===

EPP requires sufficient cardiopulmonary reserve to tolerate permanent single-lung physiology. Specific thresholds vary by institution but generally include adequate predicted postoperative FEV1, acceptable DLCO, and satisfactory cardiac function assessed by echocardiography.<ref name="ers_20" /> Performance status must be ECOG 0 to 1. There is no formal age cutoff, though outcomes deteriorate with advancing age, and most contemporary protocols exercise caution with patients over 70 years.<ref name="sugarbaker_14" /><ref name="mesoatty" />

== What Are the Survival Outcomes After EPP? ==

Survival after EPP varies dramatically depending on patient selection, histology, nodal status, and completeness of resection. The following data represent the largest published series.<ref name="dandell_treatment" /><ref name="mlc_surgery" />

=== Overall EPP Survival ===

{| class="wikitable" style="width:100%; border-collapse:collapse;"
|-
! style="background:#1a5276; color:white; padding:10px;" | Series
! style="background:#1a5276; color:white; padding:10px;" | Patients
! style="background:#1a5276; color:white; padding:10px;" | 30-Day Mortality
! style="background:#1a5276; color:white; padding:10px;" | Median OS
! style="background:#1a5276; color:white; padding:10px;" | 5-Year Survival
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Sugarbaker 1999
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 183
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 3.8%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 19 months
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 15%
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Sugarbaker 2014
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 529
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 5.0%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 18 months
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 14%
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Flores 2008
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 385 (EPP arm)
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 7.0%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 12 months
| style="padding:10px; border-bottom:1px solid #dee2e6;" | —
|-
| style="padding:10px;" | MARS Trial 2011
| style="padding:10px;" | 24 (16 completed)
| style="padding:10px;" | 12.5%
| style="padding:10px;" | 14.4 months
| style="padding:10px;" | —
|}

=== Survival by Nodal Status ===

Lymph node involvement is the strongest independent prognostic variable after EPP. The Sugarbaker 529-patient series demonstrated a clear survival gradient:<ref name="sugarbaker_14" />

{| class="wikitable" style="width:60%; border-collapse:collapse;"
|-
! style="background:#1a5276; color:white; padding:10px;" | Node Status
! style="background:#1a5276; color:white; padding:10px;" | Patients
! style="background:#1a5276; color:white; padding:10px;" | Median OS
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | N0 (negative)
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 224
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''26 months'''
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | N1
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 118
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 17 months
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | N2
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 181
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 13 months
|-
| style="padding:10px;" | N3
| style="padding:10px;" | 5
| style="padding:10px;" | 7 months
|}

=== The Favorable Triad ===

The most cited finding in EPP outcomes research is the ''favorable triad'' identified by Sugarbaker in 1999: patients with '''epithelioid histology''', '''negative resection margins''', and '''negative extrapleural lymph nodes''' achieved 68% two-year survival, '''46% five-year survival''', and a median of 51 months. This subgroup comprised only 31 of 183 patients (17%).<ref name="sugarbaker_99" /> This result has not been consistently replicated at other centers but remains the benchmark cited by EPP advocates.<ref name="mesonet_treatment" /><ref name="dandell_surgery" />

== What Complications Can Occur After EPP? ==

EPP carries substantially higher morbidity and mortality than [[Pleurectomy and Decortication|P/D]]. The overall major complication rate after EPP is approximately '''62%''' compared to 27.9% for P/D, and 30-day operative mortality is '''6.8%''' versus 2.9% for P/D.<ref name="batirel" /><ref name="mlc_surgery" />

=== Major Complications ===

{| class="wikitable" style="width:100%; border-collapse:collapse;"
|-
! style="background:#1a5276; color:white; padding:10px;" | Complication
! style="background:#1a5276; color:white; padding:10px;" | EPP Rate
! style="background:#1a5276; color:white; padding:10px;" | P/D Rate
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Overall morbidity
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''62.0%'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 27.9%
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 30-day mortality
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''6.8%'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 2.9%
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Atrial fibrillation
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 17.6–44.2%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 7.4%
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Bronchopleural fistula
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 2.3%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 0.4%
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | DVT/PE
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 3.3%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 1.4%
|-
| style="padding:10px;" | Serious respiratory complications
| style="padding:10px;" | 10.0%
| style="padding:10px;" | 6.4%
|}

Atrial fibrillation is the most common complication, occurring in '''44.2%''' of patients in the Sugarbaker 328-patient series (2004).<ref name="sugarbaker_04" /> Other significant complications include vocal cord paralysis (6.7%), prolonged intubation (7.9%), bronchopleural fistula, cardiac herniation if pericardial reconstruction fails, empyema, and pulmonary embolism.<ref name="sugarbaker_04" /><ref name="comp_review" /> A 2022 meta-analysis confirmed that atrial fibrillation, hemorrhage, pulmonary embolism, air leak, and reoperation were all significantly increased after EPP compared to P/D (p < 0.05).<ref name="meta_22" /> Pulmonary embolism has been identified as the most common cause of perioperative mortality following EPP.<ref name="comp_review" /><ref name="dandell_treatment" />

Median postoperative hospital stay is approximately '''10 to 11 days''', with national database analysis reporting a mean length of stay of 11.2 days.<ref name="sugarbaker_14" /><ref name="costs_19" />

== How Does EPP Affect Quality of Life? ==

EPP results in substantially greater pulmonary function loss than P/D. A 2021 study from Zurich documented FEV1 declining from '''76% predicted to 48% predicted''' after EPP, compared with 82% to 65% after P/D.<ref name="qol_zurich" /><ref name="mesonet_treatment" />

A 2018 systematic review encompassing 659 patients (102 EPP, 432 P/D) across 14 datasets found that quality of life remained compromised at 6 months following both procedures, but P/D patients had better scores across all measures including physical function, social function, and global health status.<ref name="qol_review" /> Critically, only P/D patients demonstrated return to baseline quality of life at 12 months; EPP patients did not reach pre-surgical quality of life levels within the study follow-up periods.<ref name="qol_review" /><ref name="mlc_treatment" />

In the MARS trial, quality of life scores were lower in the EPP group at all time points, with particularly striking differences at 6 weeks post-surgery (global health: 33.3 versus 75.0), though the small sample size limited statistical significance.<ref name="mars_11" /> Despite these findings, the 2021 Zurich study argued that quality of life alone should not be used as an argument against EPP, noting that both procedures ultimately achieved similar long-term functional outcomes in survivors.<ref name="qol_zurich" /> This remains a minority view in the mesothelioma surgical community.<ref name="dandell_surgery" />

== How Does EPP Compare to Pleurectomy/Decortication? ==

The EPP versus [[Pleurectomy and Decortication|P/D]] debate is the central controversy in mesothelioma surgery, with accumulating evidence favoring the less radical lung-sparing approach.<ref name="mesoatty" /><ref name="dandell_surgery" />

=== Arguments for EPP ===

Proponents of EPP argue that complete removal of the lung allows for more thorough macroscopic complete resection in certain anatomic configurations where tumor extensively involves the visceral pleura.<ref name="pmc_epp" /> EPP also enables full-dose hemithoracic radiation therapy without the risk of radiation pneumonitis, since no lung tissue remains to be damaged.<ref name="mesonet_treatment" /> The Sugarbaker favorable triad data, showing 46% five-year survival in selected patients, remains the strongest argument for EPP in appropriate candidates.<ref name="sugarbaker_99" /> Additionally, local recurrence rates are lower after EPP (33%) compared to P/D (65%) in registry data.<ref name="flores_08" />

=== Arguments Against EPP ===

The evidence against EPP has grown substantially. The '''MARS trial''' (2011) randomized 50 patients and found median survival of only 14.4 months for EPP versus 19.5 months without EPP (HR 2.75).<ref name="mars_11" /> While designed as a feasibility study, the results were striking. The '''MARS 2 trial''' (2024) showed that even the less morbid P/D did not improve survival over chemotherapy alone (19.3 versus 24.8 months), further undermining the rationale for the more radical EPP.<ref name="mars2_24" />

Meta-analyses consistently show EPP carries '''2.5-fold higher short-term mortality''' than P/D (4.5% vs. 1.7%, Taioli 2015, 2,903 patients) and significantly higher overall morbidity (62% vs. 27.9%).<ref name="taioli_15" /><ref name="batirel" /> While EPP achieves better local control (33% local recurrence vs. 65% for P/D), it is associated with '''higher distant recurrence''' (66% vs. 35%), possibly due to immunosuppression from losing the lung and its lymphatic tissue.<ref name="flores_08" /><ref name="mlc_surgery" /> Modern radiation techniques including intensity-modulated radiation therapy (IMRT) and proton therapy can now deliver targeted pleural radiation with the lung in situ, weakening one of the historical advantages of EPP.<ref name="asco_25" />

{| class="wikitable" style="width:100%; border-collapse:collapse;"
|-
! style="background:#1a5276; color:white; padding:10px;" | Metric
! style="background:#1a5276; color:white; padding:10px;" | EPP
! style="background:#1a5276; color:white; padding:10px;" | P/D
! style="background:#1a5276; color:white; padding:10px;" | Source
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 30-day mortality
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''4.5%'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 1.7%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Taioli 2015 (n=2,903)
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Overall morbidity
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''62.0%'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 27.9%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Batirel systematic review
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Local recurrence
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 33%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''65%'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Flores 2008
|-
| style="padding:10px;" | Distant recurrence
| style="padding:10px;" | '''66%'''
| style="padding:10px;" | 35%
| style="padding:10px;" | Flores 2008
|}

== What Role Does EPP Play in Multimodal Treatment? ==

EPP is never performed as a standalone treatment. It is always integrated into a multimodal strategy combining surgery with systemic chemotherapy and, in many protocols, radiation therapy.<ref name="dandell_treatment" /><ref name="mesonet_treatment" />

=== The Sugarbaker Trimodal Protocol ===

The classic Brigham and Women's protocol follows the sequence: '''EPP followed by adjuvant chemotherapy (cisplatin and pemetrexed) followed by hemithoracic radiation therapy'''.<ref name="sugarbaker_99" /> A multicenter phase II trial of neoadjuvant pemetrexed/cisplatin followed by EPP and radiation achieved median overall survival of 16.8 months for intention-to-treat patients and 29.1 months for patients completing all three modalities, with surgical mortality of 3.7%.<ref name="mlc_treatment" />

=== The SMART Protocol ===

The Surgery for Mesothelioma After Radiation Therapy (SMART) protocol, developed by de Perrot and colleagues at Princess Margaret Cancer Centre in Toronto, reverses the traditional treatment sequence: '''accelerated hemithoracic IMRT (25 Gy in 5 fractions) followed by EPP within approximately one week'''.<ref name="smart_21" /> The published phase II results from 96 treated patients demonstrated 30-day mortality of only '''1%''' (one patient) and grade 3-4 complications in 49%. For the epithelioid, node-negative subgroup (19 patients), the SMART protocol achieved a remarkable '''median survival of 65.9 months'''.<ref name="smart_21" /><ref name="dandell_surgery" />

=== EPP and Immunotherapy ===

Several phase I and II clinical trials are investigating the combination of immune checkpoint inhibitors with surgical resection for mesothelioma. Perioperative pembrolizumab, nivolumab, and nivolumab plus ipilimumab are all under active study.<ref name="immuno_25" /> However, most contemporary surgical immunotherapy trials use P/D rather than EPP as the surgical modality, reflecting the broader shift away from EPP.<ref name="immuno_25" /><ref name="mesoatty_claims" />

== What Are the Recurrence Patterns After EPP? ==

Understanding where mesothelioma recurs after EPP is essential for planning adjuvant treatment and surveillance. The foundational study by Baldini and colleagues (1997) characterized recurrence patterns in 49 patients undergoing EPP with adjuvant chemotherapy and hemithoracic radiation, finding an overall recurrence rate of '''54%''' at a median of 19 months.<ref name="baldini_97" /><ref name="mlc_surgery" />

An updated 2015 analysis of 169 patients treated from 2001 to 2010 with modern adjuvant regimens found a higher overall recurrence rate of '''75%''' at a median of 13.1 months. The distribution of recurrence sites remained strikingly similar to the 1997 report despite advances in radiation technique:<ref name="baldini_15" />

{| class="wikitable" style="width:80%; border-collapse:collapse;"
|-
! style="background:#1a5276; color:white; padding:10px;" | Recurrence Site
! style="background:#1a5276; color:white; padding:10px;" | 1997 (n=49)
! style="background:#1a5276; color:white; padding:10px;" | 2015 (n=169)
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Ipsilateral hemithorax (local)
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 35%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''54%'''
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Abdomen
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 26%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 39%
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Contralateral hemithorax
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 17%
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 28%
|-
| style="padding:10px;" | Other distant sites
| style="padding:10px;" | 8%
| style="padding:10px;" | 5%
|}

When comparing recurrence patterns between EPP and P/D, EPP achieves better local control (33% local recurrence vs. 65% for P/D) but is associated with significantly higher distant recurrence (66% vs. 35%).<ref name="flores_08" /> This paradox may result from the immunosuppressive effect of removing the lung and its lymphatic tissue, which may compromise the body's ability to contain distant spread.<ref name="mesonet" /><ref name="dandell_treatment" />

== How Much Does EPP Cost? ==

EPP is among the most expensive surgical procedures for mesothelioma. Based on 2014 National Inpatient Sample (NIS) data, the mean hospital cost for pneumonectomy in mesothelioma patients was '''$62,408''' (95% CI: $48,385 to $76,431), compared to $53,993 for [[Pleurectomy and Decortication|P/D]] and $24,901 for the average mesothelioma hospitalization.<ref name="costs_19" /><ref name="dandell_comp" />

These figures represent hospital charges only and do not include surgeon and anesthesia fees, the cost of neoadjuvant or adjuvant chemotherapy, radiation therapy, rehabilitation, or long-term follow-up care. A comprehensive cost-effectiveness analysis comparing the full EPP multimodal pathway to the P/D pathway or to chemotherapy alone has not been published.<ref name="costs_19" /> For more detailed information on [[Mesothelioma Treatment Costs|treatment costs]], see our comprehensive guide. Mesothelioma patients may offset these expenses through [[Asbestos Trust Funds|asbestos trust fund]] claims and legal compensation.<ref name="mesoatty_claims" /><ref name="dandell_comp" />

== What Do Current Medical Guidelines Say About EPP? ==

The consensus of major medical guidelines has shifted decisively away from EPP and toward lung-sparing approaches.<ref name="mlc_treatment" /><ref name="dandell_treatment" />

{| class="wikitable" style="width:100%; border-collapse:collapse;"
|-
! style="background:#1a5276; color:white; padding:10px;" | Organization
! style="background:#1a5276; color:white; padding:10px;" | Year
! style="background:#1a5276; color:white; padding:10px;" | Position on EPP
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''NCCN'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 2025
| style="padding:10px; border-bottom:1px solid #dee2e6;" | P/D recommended over EPP; surgery limited to stage I disease
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''ASCO'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 2025
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Hemithoracic adjuvant RT may be offered post-EPP at centers of excellence; neoadjuvant RT + EPP only in clinical trials
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | '''ERS/ESTS/EACTS/ESTRO'''
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 2020
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Radical surgery candidates should be treated in clinical trials at dedicated centers
|-
| style="padding:10px;" | '''British Thoracic Society'''
| style="padding:10px;" | 2018
| style="padding:10px;" | ''"Do not offer Extra-Pleural Pneumonectomy in MPM"'' (Grade B recommendation)
|}

The BTS recommendation against EPP is the most explicit, while the ASCO guidelines maintain a narrow window for EPP at centers of excellence with hemithoracic radiation capability.<ref name="bts_18" /><ref name="asco_25" /> The European joint guidelines emphasize that both EPP and extended P/D remain options in principle but should be performed within clinical trials at specialized mesothelioma centers.<ref name="ers_20" /><ref name="mesonet" />

== Where Is EPP Performed? ==

Surgical volume and institutional expertise are strongly correlated with EPP outcomes. Patients treated at specialized mesothelioma centers have been reported to have '''20 to 40% better survival''' than those at general hospitals, with surgical mortality two to three times lower at high-volume centers.<ref name="mlnm_centers" /><ref name="dandell" />

{| class="wikitable" style="width:100%; border-collapse:collapse;"
|-
! style="background:#1a5276; color:white; padding:10px;" | Center
! style="background:#1a5276; color:white; padding:10px;" | Key Surgeons
! style="background:#1a5276; color:white; padding:10px;" | Notable Contribution
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Brigham and Women's / Dana-Farber
| style="padding:10px; border-bottom:1px solid #dee2e6;" | David Sugarbaker (d. 2018), Raphael Bueno
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Largest single-institution EPP series (529+ patients)
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Memorial Sloan Kettering
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Valerie Rusch, Raja Flores
| style="padding:10px; border-bottom:1px solid #dee2e6;" | 663-patient international registry
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | MD Anderson Cancer Center
| style="padding:10px; border-bottom:1px solid #dee2e6;" | David Rice
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Pioneering lung-sparing techniques
|-
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Princess Margaret, Toronto
| style="padding:10px; border-bottom:1px solid #dee2e6;" | Marc de Perrot
| style="padding:10px; border-bottom:1px solid #dee2e6;" | SMART protocol innovator
|-
| style="padding:10px;" | University Hospital Zurich
| style="padding:10px;" | Walter Weder, Isabelle Opitz
| style="padding:10px;" | EPP mortality 2.2% in Swiss multimodality trial
|}

A retrospective single-institution study spanning 18 years confirmed that higher patient volumes were associated with lower perioperative morbidity and better overall survival, with mortality rates of 6% or less documented only at high-volume centers performing EPP as part of multimodality treatment.<ref name="mlc_surgery" /><ref name="mesonet_treatment" />

== Frequently Asked Questions ==

=== Is EPP still performed for mesothelioma? ===

Yes, but in very limited circumstances. EPP is still performed at a small number of high-volume mesothelioma centers for highly selected patients with early-stage (T1-3, N0), epithelioid mesothelioma and excellent performance status. However, its use has declined significantly following the MARS trial results, and current guidelines from the NCCN and BTS recommend P/D over EPP.<ref name="asco_25" /><ref name="bts_18" /><ref name="dandell_surgery" />

=== What is the difference between EPP and P/D? ===

EPP removes the entire affected lung along with the pleura, pericardium, and diaphragm. [[Pleurectomy and Decortication|P/D]] removes only the pleura (and sometimes the pericardium and diaphragm in extended P/D) while preserving the lung. P/D has lower operative mortality (1.7% vs. 4.5%), lower morbidity (27.9% vs. 62%), and is now the preferred surgical approach for mesothelioma.<ref name="taioli_15" /><ref name="batirel" /><ref name="mlc_surgery" />

=== What is the Sugarbaker favorable triad? ===

The favorable triad refers to the combination of epithelioid histology, negative surgical margins, and negative extrapleural lymph nodes. In the Sugarbaker 1999 study, 31 patients with all three favorable factors achieved 46% five-year survival and median survival of 51 months, the best outcomes ever reported for EPP.<ref name="sugarbaker_99" /><ref name="dandell_treatment" />

=== What is the SMART protocol? ===

SMART (Surgery for Mesothelioma After Radiation Therapy) is an experimental protocol developed at Princess Margaret Cancer Centre in Toronto that reverses the traditional treatment sequence by delivering accelerated hemithoracic radiation (25 Gy in 5 fractions) before EPP. In the epithelioid, node-negative subgroup, the SMART protocol achieved median survival of 65.9 months with only 1% 30-day mortality.<ref name="smart_21" /><ref name="mesonet_treatment" />

=== Can I receive compensation for mesothelioma treatment costs? ===

Yes. Mesothelioma patients may be eligible for compensation through multiple pathways, including [[Asbestos Trust Funds|asbestos trust fund]] claims, [[Mesothelioma Settlements|personal injury lawsuits]], VA benefits for veterans, and workers' compensation. Over $30 billion remains available in active asbestos trust funds. An experienced [[Mesothelioma Claim Process|mesothelioma attorney]] can help evaluate which compensation options apply to your specific situation.<ref name="dandell_comp" /><ref name="mesoatty_claims" /><ref name="mlc" />

=== What are the contraindications for EPP? ===

Absolute contraindications include sarcomatoid histology, N3 nodal disease, distant metastatic disease, contralateral pleural involvement, poor performance status (ECOG 2 or higher), and insufficient cardiopulmonary reserve for single-lung physiology. Relative contraindications include N2 mediastinal nodal disease, biphasic histology, advanced age over 70 to 75 years, T4 disease with chest wall invasion, and significant cardiac comorbidity.<ref name="sugarbaker_14" /><ref name="ers_20" /><ref name="dandell_surgery" />

== Get Help ==

Mesothelioma patients and families can connect with experienced legal and medical advocates:

* [https://dandell.com/contact-us/ Danziger & De Llano] provides free case evaluations and can connect families with specialized treatment centers — call (866) 222-9990
* [https://www.mesotheliomalawyercenter.org/mesothelioma/ Mesothelioma Lawyer Center] offers resources on treatment options and legal rights
* [https://mesothelioma.net/mesothelioma-treatment/ Mesothelioma.net] provides comprehensive information on surgical options

== Quick Statistics ==

* EPP use declined from majority-share to only 11% of mesothelioma surgical cases between 2005 and 2025, while P/D rose to 57%<ref name="asco_25" />
* The Sugarbaker 529-patient series found node-negative patients survived twice as long as N2-positive patients — 26 months vs. 13 months median<ref name="sugarbaker_14" />
* Recurrence after EPP increased from 54% in 1997 data to 75% in 2015 data despite improved adjuvant regimens<ref name="baldini_97" /><ref name="baldini_15" />
* Abdominal recurrence after EPP rose from 26% to 39% between the 1997 and 2015 Baldini analyses, suggesting transdiaphragmatic tumor spread during reconstruction<ref name="baldini_97" /><ref name="baldini_15" />
* The SMART protocol achieved only 1% 30-day mortality across 96 patients, well below the 3.8–7% range in conventional EPP series<ref name="smart_21" /><ref name="sugarbaker_99" />
* A 2022 meta-analysis confirmed EPP carries significantly higher rates of atrial fibrillation, hemorrhage, pulmonary embolism, air leak, and reoperation compared to P/D<ref name="meta_22" />
* EPP hospital costs exceed the average mesothelioma hospitalization by 2.5 times — $62,408 vs. $24,901 mean charges<ref name="costs_19" />
* Over $30 billion remains available in asbestos trust funds to help offset surgical and multimodal treatment costs<ref name="dandell_comp" />
* Quality of life after EPP remains below baseline at 12 months, while P/D patients typically return to pre-surgical function within the same timeframe<ref name="qol_review" />
* The European joint guidelines (ERS/ESTS/EACTS/ESTRO 2020) recommend that all radical mesothelioma surgery, including EPP, be performed exclusively within clinical trials at dedicated centers<ref name="ers_20" />

== Related Pages ==

* [[Mesothelioma Surgery Overview|Mesothelioma Surgery Overview]] — comprehensive guide to all surgical options
* [[Pleurectomy and Decortication|Pleurectomy and Decortication (P/D)]] — the preferred lung-sparing alternative
* [[Mesothelioma Treatment Costs|Mesothelioma Treatment Costs]] — financial analysis of treatment options
* [[Understanding Your Diagnosis|Understanding Your Diagnosis]] — diagnosis types, staging, and prognosis
* [[Mesothelioma Diagnosis and Staging|Mesothelioma Diagnosis and Staging]]
* [[Mesothelioma Settlements|Mesothelioma Settlements and Verdicts]]
* [[Asbestos Trust Funds|Asbestos Trust Funds]] — $30+ billion available for mesothelioma victims

{{Statute Warning}}

<span data-nosnippet class="noai-content">
{{CTA Box|}}
</span>

== References ==
<references>
<ref name="pmc_epp">[https://pmc.ncbi.nlm.nih.gov/articles/PMC6462700/ Extra-pleural pneumonectomy], Annals of Translational Medicine, PMC6462700 (2019)</ref>
<ref name="sugarbaker_99">[https://pubmed.ncbi.nlm.nih.gov/9869758/ Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: results in 183 patients], Sugarbaker DJ et al., Journal of Thoracic and Cardiovascular Surgery (1999)</ref>
<ref name="sugarbaker_04">[https://pubmed.ncbi.nlm.nih.gov/15224033/ Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies], Sugarbaker DJ et al., Journal of Thoracic and Cardiovascular Surgery (2004)</ref>
<ref name="sugarbaker_14">[https://pubmed.ncbi.nlm.nih.gov/25203873/ Novel prognostic implications of combined N1 and N2 lymph node status after extrapleural pneumonectomy for malignant pleural mesothelioma: results in 529 patients], Sugarbaker DJ et al., Journal of Thoracic and Cardiovascular Surgery (2014)</ref>
<ref name="flores_08">[https://pubmed.ncbi.nlm.nih.gov/18329481/ Extrapleural pneumonectomy versus pleurectomy/decortication in the surgical management of malignant pleural mesothelioma: results in 663 patients], Flores RM et al., Journal of Thoracic and Cardiovascular Surgery (2008)</ref>
<ref name="mars_11">[https://pubmed.ncbi.nlm.nih.gov/21723781/ Clinical outcomes of the Mesothelioma and Radical Surgery (MARS) randomised trial], Treasure T et al., Lancet Oncology (2011)</ref>
<ref name="mars2_24">[https://pubmed.ncbi.nlm.nih.gov/38740044/ Extended pleurectomy decortication and chemotherapy versus chemotherapy alone for pleural mesothelioma (MARS 2)], Lim E et al., Lancet Respiratory Medicine (2024)</ref>
<ref name="taioli_15">[https://pubmed.ncbi.nlm.nih.gov/25534527/ Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma], Taioli E et al., Annals of Thoracic Surgery (2015)</ref>
<ref name="meta_22">[https://pubmed.ncbi.nlm.nih.gov/36057027/ Meta-analysis of survival after extrapleural pneumonectomy versus pleurectomy/decortication in malignant pleural mesothelioma], Journal of Cardiothoracic Surgery (2022)</ref>
<ref name="smart_21">[https://pubmed.ncbi.nlm.nih.gov/33450184/ Surgery for malignant pleural mesothelioma after radiotherapy (SMART): final results of a multicentre, phase 2 trial], de Perrot M et al., Lancet Oncology (2021)</ref>
<ref name="baldini_97">[https://pubmed.ncbi.nlm.nih.gov/9033296/ Patterns of failure after trimodality therapy for malignant pleural mesothelioma], Baldini EH et al., Annals of Thoracic Surgery (1997)</ref>
<ref name="baldini_15">[https://pmc.ncbi.nlm.nih.gov/articles/PMC6042876/ Updated patterns of failure after multimodality therapy for malignant pleural mesothelioma], Baldini EH et al., Journal of Thoracic and Cardiovascular Surgery (2015)</ref>
<ref name="costs_19">[https://pmc.ncbi.nlm.nih.gov/articles/PMC6637828/ Costs of medical care for mesothelioma], Lung Cancer, PMC6637828 (2019)</ref>
<ref name="qol_review">[https://pmc.ncbi.nlm.nih.gov/articles/PMC6267825/ Systematic review of quality of life following pleurectomy decortication and extrapleural pneumonectomy for malignant pleural mesothelioma], Schwartz RM et al., BMC Cancer (2018)</ref>
<ref name="qol_zurich">[https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2021.766033/full Quality of Life Is Not Deteriorated After Extrapleural Pneumonectomy Compared to Pleurectomy/Decortication], Ploenes T et al., Frontiers in Surgery (2021)</ref>
<ref name="pmc_recon">[https://pmc.ncbi.nlm.nih.gov/articles/PMC5830557/ Diaphragmatic and pericardial reconstruction after surgery for malignant pleural mesothelioma], PMC5830557, Journal of Visualized Surgery (2018)</ref>
<ref name="ers_20">[https://pubmed.ncbi.nlm.nih.gov/32451346/ ERS/ESTS/EACTS/ESTRO guidelines for the management of malignant pleural mesothelioma], European Respiratory Journal (2020)</ref>
<ref name="bts_18">[https://thorax.bmj.com/content/73/Suppl_1/i1 British Thoracic Society Guideline for the investigation and management of malignant pleural mesothelioma], Thorax (2018)</ref>
<ref name="asco_25">[https://ascopubs.org/doi/10.1200/JCO-24-02425 Treatment of Pleural Mesothelioma: ASCO Guideline Update], Journal of Clinical Oncology (2025)</ref>
<ref name="nci">[https://www.cancer.gov/types/mesothelioma/patient/mesothelioma-treatment-pdq Mesothelioma Treatment], National Cancer Institute (NCI)</ref>
<ref name="batirel">[https://jtd.amegroups.org/article/view/18679/html Pleurectomy/decortication versus extrapleural pneumonectomy for the treatment of malignant pleural mesothelioma], Batirel HF, Journal of Thoracic Disease (2013)</ref>
<ref name="comp_review">[https://shc.amegroups.org/article/view/4385/5170 Complications following radical surgery for malignant pleural mesothelioma], Shanghai Chest (2018)</ref>
<ref name="immuno_25">[https://pmc.ncbi.nlm.nih.gov/articles/PMC12905100/ Immunotherapy advances in pleural mesothelioma], PMC12905100 (2025)</ref>
<ref name="dandell">[https://dandell.com/ Danziger & De Llano], Mesothelioma Attorneys</ref>
<ref name="dandell_treatment">[https://dandell.com/mesothelioma/treatment/ Mesothelioma Treatment Options], Danziger & De Llano</ref>
<ref name="dandell_surgery">[https://dandell.com/mesothelioma/surgery/ Mesothelioma Surgery], Danziger & De Llano</ref>
<ref name="dandell_comp">[https://dandell.com/mesothelioma/compensation/ Mesothelioma Compensation], Danziger & De Llano</ref>
<ref name="mlc">[https://mesotheliomalawyercenter.org/ Mesothelioma Lawyer Center]</ref>
<ref name="mlc_treatment">[https://mesotheliomalawyercenter.org/mesothelioma/treatment/ Mesothelioma Treatment], Mesothelioma Lawyer Center</ref>
<ref name="mlc_surgery">[https://mesotheliomalawyercenter.org/mesothelioma/surgery/ Mesothelioma Surgery Options], Mesothelioma Lawyer Center</ref>
<ref name="mesonet">[https://mesothelioma.net/ Mesothelioma.net]</ref>
<ref name="mesonet_treatment">[https://mesothelioma.net/mesothelioma-treatment/ Mesothelioma Treatment], Mesothelioma.net</ref>
<ref name="mesoatty">[https://mesotheliomaattorney.com/ MesotheliomaAttorney.com]</ref>
<ref name="mesoatty_claims">[https://mesotheliomaattorney.com/mesothelioma-claims/ Mesothelioma Claims], MesotheliomaAttorney.com</ref>
<ref name="mlnm_centers">[https://mesotheliomalawyersnearme.com/blog/mesothelioma-treatment-centers-top-6-specialists-2026/ Top 6 Mesothelioma Treatment Centers], Mesothelioma Lawyers Near Me (2026)</ref>
</references>

[[Category:Mesothelioma]]
[[Category:Medical]]
[[Category:Treatment]]
[[Category:Surgery]]
[[Category:Extrapleural Pneumonectomy]]
[[Category:Pleural Mesothelioma]]
[[Category:Clinical Trials]]
[[Category:MARS Trial]]