Pneumonectomy

A pneumonectomy is the surgical removal of an entire lung and is usually performed as a cancer treatment. There are two types of pneumonectomy:

1) traditional pneumonectomy, in which only the diseased lung is removed and;

2) extrapleural pneumonectomy (sometimes also called a pleuropneumonectomy) in which the lung is removed as well as areas of the diaphragm, and the covering of the heart.

The pneumonectomy used in cases of malignant mesothelioma. Malignant mesothelioma is a cancer of the pleura (the membrane lining the lungs) and therefore the pneumonectomy required to treat this disease, must remove not only the diseased lung, but a portion of the pericardium (the membrane covering the heart), part of the diaphragm and the parietal pleura (the membrane lining the chest cavity) on the same side of the chest. This procedure is called a extrapleural pneumonectomy.

Within the medical community there is a debate over the effectiveness of this surgery. The surgery itself is dangerous with nearly 5 to 10% of patients not surviving. However, new procedures have improved these odds in recent years. Advocates of the surgery, including an outspoken doctor in Boston believe it is the most effective way to treat mesothelioma. They point to 3 and 4 year survival rates in many patients who have had sucessful surgeries. Other doctors are not so sure and argue that this invasve procedure is not worth the risks, especially in older patients.

An extrapleural pneumonectomy is considered the best surgical option when a tumor is located in the middle of the lung and involves a significant portion of the pulmonary artery or veins. However, because the surgery is risky and diminishes half of a patient's breathing capacity surgeons usually regard it as a last option and will usually first consider a pleurectomy. A Pleurectomy is a more complicated procedure, but is lung sparing involving only the removal of the pleura. Which treatment is recommended depends on many factors, including the stage of the tumor.

Overall it is unclear if extra-pleural pneumonectomy provides significantly greater benefits than pleurectomy, and if either is significantly more effective than non-surgical options (there is debate).

Pleurectomy can be technically more difficult and complex than the extrapleural pneumonectomy. However, the mortality of pleurectomy is more favorable (1.5%-5% by an experienced surgeon) and though extrapleural pneumonectomy may appear to be more effective in removing more of the tumor by the en bloc resection, when performed early enough, pleurectomy is equally effective. In later stage mesothelioma, when there is a tumor invasion of the lung parenchyma, pleurectomy is no longer an option.

A recent study designed to compare the effectiveness of pleurectomy, and extra-pleural pneumonectomy reveal that neither was more effective than the other in extending survival rates. Rather, other factors seemed to determine how long people survived. These factors included the stage and cell type of the tumor, the gender of the patient, and the type of treatment(s) given in conjunction with the surgery.

Pleurectomy can provide symptomatic relief and sometimes the bulk of the tumor can be removed. It is often used in combination with other treatments, but its value is very limited if the tumor is near any vital organs. Additionally, it is a complex surgery, not performed by most surgeons. Most patients are referred to centers dedicated to such treatments. Many of these centers also specialize in other forms of mesothelioma treatment, either alone or in combination (multi-modal therapy).

Before any surgery is considered for the treatment of malignant mesothelioma, the patient's overall health must be carefully evaluated. Tests should be performed to make sure the patient has no metastasis disease (cancer spread to distant sites) and to evaluate the patient's lung and heart function. These operations are only possible if a patient is fit enough and has good heart and lung function. If the patient's heart and lung function is poor, the operation may do more harm than good. With mesothelioma, a patient's lungs are often compromised for several reasons. Pleural fluid build up and tumor mass caused by mesothelioma can compress the lung. Also, the patient's exposure to asbestos may have decreased lung function, which also decreases with age. In addition, some patients have a history of smoking cigarettes, which further decreases lung function, and may render both procedures non-options.