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Extrapleural pneumonectomy (EPP) is an aggressive operation that entails the resection of the entire lung, visceral pleura, parietal pleura, and usually the pericardium and/or diaphragm, which generally require prosthetic reconstruction. In the 1940s, Sarot first described the technique of EPP for tuberculous empyema.1,2 In 1976, Butchart et al. reported the application of EPP in the management of diffuse pleural mesothelioma in 29 patients with a prohibitive operative mortality of 31%.3 Over the next two decades, there was increased application of EPP in the multimodality management of malignant pleural mesothelioma (MPM) with attendant significant improvements in mortality rates.47 In 2004, Sugarbaker et al. reported the lowest published operative mortality of 3.4%.8 These results from the Brigham and Women’s Hospital/Dana Farber Cancer Institute represented the largest single-institution review of 328 patients with MPM who underwent EPP between 1980 and 2000.8 A management approach focused on prevention, early detection, and aggressive treatment of the most common postoperative complications was instituted with resultant reduction in mortality.8

MPM is a rare aggressive cancer associated with asbestos exposure and poor prognosis. Beebe-Dimmer et al. reported on patients with malignant mesothelioma of the pleura or peritoneum between 2005 and 2009, and they described treatment patterns and overall survival (OS) based on the Surveillance, Epidemiology, and End Results (SEER-Medicare) database.9 The median OS among patients that received chemotherapy compared to no chemotherapy was 12 months (1–69 months) versus 4 months (1–69 months), respectively.9 In contrast, patients that underwent surgery and chemotherapy compared to surgery alone had a median OS of 16 months (4–56 months) versus 5 months (1–47 months), respectively.9 As such, contemporary studies have focused on multimodality treatment strategies that incorporate aggressive surgery. Unfortunately, upon diagnosis, the majority of patients with MPM have advanced disease with significant compromise in functional status, making them unresectable. Surgery for MPM has focused on macroscopic complete resection (MCR) as part of a multimodality treatment approach in the minority of patients with localized MPM and optimal functional status suitable for major surgery.1012 Both extended pleurectomy decortication (EPD)1316 and EPP48,1720 have been employed in this population to achieve MCR and prolonged OS.20,21 Taioli et al. reported on a meta-analysis evaluating the long-term outcomes of EPD (1512 patients) versus EPP (1391 patients) identified between 1990 and 2014.16 There was a significantly higher number of short-term deaths in the EPP group compared to EPD (4.5 vs. 1.7%; p < 0.05) and no statistically significant difference in long-term mortality at 2 years.16 While both techniques have achieved long-term OS, particularly in patients with small tumor burden and epithelioid histology, the likelihood of completing multimodality treatment is better with EPD compared to EPP.12 However, in select patients with high tumor burden, EPP may have a role in achieving ...

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