Nonlinear extensional flows are common in polymer processing but remain challenging theoretically because dramatic stretching of chains deforms the entanglement network far from equilibrium. Here, we present coarse-grained simulations of extensional flows in entangled polymer melts for Rouse-Weissenberg numbers $Wi_R=0.06$-$52$ and Hencky strains $epsilongeq6$. Simulations reproduce experimental trends in extensional viscosity with time, rate and molecular weight. Studies of molecular structure reveal an elongation and thinning of the confining tube with increasing $Wi_R$. The rising stress is quantitatively consistent with the decreasing entropy of chains at the equilibrium entanglement length. Molecular weight dependent trends in viscosity are related to a crossover from the Newtonian limit to a high rate limit that scales differently with chain length.