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Extrapleural pneumonectomy for mesothelioma: what it is and who it is for | CION Cancer Clinics
An extrapleural pneumonectomy removes a whole lung along with the lining of the chest, the lining over the heart and part of the diaphragm. It is done for mesothelioma, a cancer of the chest lining, and only in a small group of fit patients with early disease. Most centres now prefer an operation that keeps the lung. This page explains what is removed, who it does not suit and what to ask. CION Cancer Clinics’ surgical oncologists in Hyderabad can talk this through with you.
MI
Medically reviewed by Dr. Mohammed ImaduddinConsultant Surgical Oncologist · MBBS, MS (General Surgery), MCh (Surgical Oncology) · last reviewed September 2026, next review due September 2027
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On this page
- What is an extrapleural pneumonectomy?
- What exactly is removed, and what is put back?
- How does it differ from the lung-sparing operation?
- What happens before, during and after the operation?
- Words you will meet on the reports, in plain language
- What families often believe, and what is true
- Who is this operation not for, and what can this page not tell you?
- Common questions about extrapleural pneumonectomy
The short answer
What is an extrapleural pneumonectomy?
An extrapleural pneumonectomy removes the whole lung on one side together with the lining around it, the lining over the heart on that side, and part of the diaphragm, the sheet of muscle under the lung. It is done for mesothelioma, a cancer of the pleura (the lining of the chest), and it is one of the largest operations in chest surgery.
Why so much is taken out
Mesothelioma does not grow as one lump. It spreads as a sheet across the whole lining of the chest, over the diaphragm and onto the sac around the heart. Removing only the lung would leave cancer on every one of those surfaces, so the operation follows the lining and takes the lung out with it, as one piece.
Where it sits today
Twenty years ago this was the standard operation for mesothelioma in fit patients. Now it is offered far less often. A gentler operation that strips the lining but leaves the lung in place, called extended pleurectomy and decortication, is chosen for most people who have surgery at all. Many centres offer extrapleural pneumonectomy only inside a clinical trial, or to a small group of younger, very fit patients with early disease.
If a surgeon has suggested this operation, it is fair to ask why this one and not the lung-sparing version.Inside the chest
What exactly is removed, and what is put back?
The lung and its lining
The whole lung on the affected side, with the pleura peeled away from the inside of the ribcage and taken with it. The airway to that lung is closed with staples and usually covered with a flap of nearby tissue.
The diaphragm on that side
The muscle sheet under the lung is removed because the cancer sits on it. It is replaced with a firm patch stitched to the ribs, so the liver or stomach cannot rise into the chest.
What that means later
- Breathing relies more on the other side
- A rare risk of the patch loosening
The sac around the heart
The lining over the heart on that side is taken and replaced with a looser patch. Without it the heart could shift or twist into the empty space, which is dangerous.
Lymph nodes
The glands in the centre of the chest are removed and sent for testing. Their report tells the team how far the cancer has travelled and shapes the treatment that follows.
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How does it differ from the lung-sparing operation?
Extrapleural pneumonectomy
Extended pleurectomy and decortication
The whole lung is removed
The lung stays; only the lining is stripped away
Breathing afterwards depends on one lung
Both lungs still work, though the treated one may stiffen
Higher chance of serious complications in the first weeks
Generally easier to recover from, but more air leak and fluid
Radiotherapy can be given to the whole empty side afterwards
Radiotherapy is limited because the lung is still there
The pathway
What happens before, during and after the operation?
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Confirming the diagnosis
Mesothelioma is confirmed by a biopsy (a piece of tissue looked at under the microscope), usually taken with a camera through a small cut in the chest. The report says which cell type it is, and surgery is only considered for the epithelioid type.
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Staging and fitness tests
A PET-CT and often an MRI check whether the cancer has crossed the diaphragm, entered the chest wall or reached the other side. Breathing tests and a heart scan check whether your body can manage on one lung. Many people are turned down here, and that is protection, not rejection.
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Chemotherapy first
Most teams give several cycles of chemotherapy before the operation to shrink the disease and to see how it behaves. If it grows through chemotherapy, surgery is usually taken off the table.
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The operation and the ICU
The surgery takes most of a day. You wake in intensive care with several drips and a drain. The first days are about protecting the heart rhythm and the remaining lung.
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Radiotherapy to the empty side
Once you have recovered enough, radiotherapy to the whole empty half of the chest is often given to treat cells left on the surfaces. This is only possible because the lung is no longer there to be damaged.
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On your report
Words you will meet on the reports, in plain language
- Pleura
- The thin double lining that wraps each lung and lines the inside of the ribcage. Mesothelioma starts here, not inside the lung itself.
- Epithelioid, sarcomatoid, biphasic
- The three cell types of mesothelioma. Surgery is usually only considered for the epithelioid type, which grows more slowly. Biphasic means a mixture.
- Trimodality
- Three treatments used together: chemotherapy, then surgery, then radiotherapy. Extrapleural pneumonectomy is almost always one part of a trimodality plan, never the whole plan.
- Macroscopic complete resection
- The surgeon could see no cancer left behind at the end of the operation. It does not mean every cell is gone; cells too small to see are the reason radiotherapy follows.
- Staging
- How far the cancer has spread, written as a stage number. With mesothelioma the stage on the scan and the stage found at surgery often differ.
Commonly believed
What families often believe, and what is true
"If they take the whole lung and the lining, the cancer is gone."
Mesothelioma spreads as a film of cells, and some are too small for any surgeon to see. This is why chemotherapy comes first and radiotherapy comes after. The operation is one part of a longer plan, and your team will not describe it as a fix on its own.
"The bigger operation must be the stronger treatment."
Trials comparing the two operations have not shown that removing the lung helps people live longer, and it is harder to recover from. That is why most surgeons now keep the lung in. Bigger is not the same as better here.
"He was refused surgery, so they have given up on him."
Being told you are not suited to this operation is the team protecting you from an operation that could do harm. Chemotherapy, immunotherapy and the lung-sparing operation remain, and for many people one of those is the better path.
Being straight with you
Who is this operation not for, and what can this page not tell you?
It is not for most people with mesothelioma. It is not offered where the cancer has crossed to the other side of the chest, into the belly or into the chest wall, where the cell type is sarcomatoid or mixed, or where the heart and the remaining lung are not strong enough to carry the whole load alone.
Age and fitness matter more than the scan
Older people, people with heart disease, and people already breathless on a flight of stairs are usually steered towards the lung-sparing operation or drug treatment. Some breathlessness after losing a lung is permanent, and the team has to be confident you will still have a life worth living afterwards.
What this page cannot tell you
It cannot tell you whether your father or mother should have this operation. That depends on the biopsy type, the scans, the breathing and heart tests, and a discussion between the surgeon, the medical oncologist and the radiation oncologist together. It cannot give you a prognosis (an idea of how things will go). What it can do is help you ask the right questions at the next appointment.
Questions we are asked
Common questions about extrapleural pneumonectomy
Can a person really live with one lung after this?
Yes. The remaining lung takes over, and over months the body adjusts. What changes is reserve. Walking on the flat and daily tasks are usually manageable; stairs, hills and hurrying will leave you more breathless than before. This is why the fitness tests before surgery are so strict.
How long is the stay in hospital?
Longer than for a routine lung operation. Expect some days in intensive care followed by a stay on the ward, usually a couple of weeks in total, and longer if the heart rhythm or the chest needs extra attention. Plan for a family member to be nearby.
Is this operation done in Hyderabad?
Very few centres anywhere do it regularly, and the number of cases in India each year is small. Ask any centre that offers it how many they have done, who the chest surgeon is, and whether cases go to a tumour board. For help finding a thoracic surgeon, call the helpline.
Why does chemotherapy come before the surgery?
Two reasons. It shrinks the disease so the surgeon has less to remove, and it shows how the cancer behaves. If it grows despite chemotherapy, a very large operation is unlikely to help, and the team can spare you from it.
What are the main risks?
Heart rhythm problems in the first days, a leak at the closed airway, infection in the empty space, and strain on the remaining lung. The risk of dying around the operation is higher than for other lung surgery, which is a major reason it is done less often now. Your surgeon should tell you their own centre's figures.
Will the pain be bad?
The cut is long and goes between the ribs, so the early pain is real. An epidural or a nerve block usually covers the first days, followed by tablets. The pain settles over weeks for most people, but some have a tender or numb patch along the scar for much longer. Tell the team early if it is not controlled.
What if we choose not to have surgery at all?
That is a valid choice and many people make it. Chemotherapy and immunotherapy are used for mesothelioma without any operation, and treatment for symptoms such as fluid on the chest can make a real difference to comfort.
Is the cost covered by Aarogyasri or insurance?
Chest cancer surgery is generally listed under Aarogyasri, CGHS, ECHS and EHS, and most cashless insurers cover it with pre-authorisation. What you pay yourself depends on the room, the ICU stay and the chemotherapy and radiotherapy around it. Call the helpline with your card details and we will check.
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Sources
- Cancer Research UK — Surgery for mesothelioma
- National Cancer Institute — Malignant Mesothelioma Treatment (PDQ) - Patient Version
- American Cancer Society — Surgery for Malignant Mesothelioma
- NHS — Mesothelioma
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Pneumonectomy: Removing an Entire LungThe standard whole-lung operation this one is built onTests to Check You Can Tolerate Losing a LungThe fitness checks that decide whether surgery is offeredCan You Live With One Lung?What daily life looks like afterwardsDeciding on Cancer SurgeryHow to weigh a large operation and get a second opinionChoosing a Surgeon and a CentreWhat to ask a centre that offers a rare operation
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