Elsevier

The Annals of Thoracic Surgery

Volume 80, Issue 6, December 2005, Pages 1988-1993
The Annals of Thoracic Surgery

Original article
General thoracic
Extended Surgical Staging for Potentially Resectable Malignant Pleural Mesothelioma

Presented at the Forty-first Annual Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24–26, 2005.
https://doi.org/10.1016/j.athoracsur.2005.06.014Get rights and content

Background

Extrapleural pneumonectomy for malignant pleural mesothelioma (MPM) is a high-risk procedure, and patients require careful preoperative staging to exclude advanced disease. Computed tomography, magnetic resonance imaging, and positron emission tomography are useful staging modalities, but do not reliably identify contralateral mediastinal involvement or transdiaphragmatic invasion. We evaluated the role of extended surgical staging procedures, which generally includes a combination of laparoscopy, peritoneal lavage, and mediastinoscopy, to more precisely stage patients with MPM.

Methods

One hundred eighteen patients with MPM, deemed clinically and radiologically resectable, underwent extended surgical staging. Mediastinoscopy was performed in 111 patients, laparoscopy in 109 patients, and peritoneal lavage in 78 patients.

Results

Ten (9.2%) patients had gross evidence of transdiaphragmatic or peritoneal involvement. Peritoneal lavage was positive for metastatic MPM in 2 (2.6%) patients, neither of whom had obvious transdiaphragmatic invasion. Ipsilateral mediastinal nodes contained metastatic tumor in 10 of 62 (16.1%) patients. Contralateral nodes were positive in 4 of 111 (3.6%) patients. Of the patients who underwent biopsy of both ipsilateral and contralateral mediastinal nodes, and who had complete pathologic staging after extrapleural pneumonectomy (n = 46), 14 (30.4%) had N2-positive nodes. Only 5 of these patients were correctly identified by mediastinoscopy (sensitivity 36%, accuracy 80%). Extended surgical staging identified 16 (13.6%) patients who had contralateral nodal involvement, transdiaphragmatic invasion, or positive peritoneal cytology.

Conclusions

Extended surgical staging defines an important subset of patients with unresectable MPM not identified by imaging. Because of the potential morbidity associated with extrapleural pneumonectomy, we advocate that extended surgical staging be performed in all patients with MPM before resection.

Section snippets

Patients and Methods

Between October 1999 and June 2004, 383 patients with MPM were evaluated at the University of Texas M.D. Anderson Cancer Center. A retrospective review was performed on 118 consecutive patients with histologically confirmed MPM who were considered to have potentially resectable MPM after undergoing extensive diagnostic imaging and physiologic screening. The study was approved by the M.D. Anderson Cancer Center Institutional Review Board. Routine diagnostic imaging included contrast enhanced CT

Results

One hundred eighteen patients were considered candidates for extrapleural pneumonectomy and underwent ESS. Patient characteristics are presented in Table 1. Laparoscopy was performed in 109 patients. Nine (8.3%) patients had transdiaphragmatic extension of tumor, and 1 (0.9%) patient had diffuse peritoneal metastases. A review of axial CT images (n = 4) and CT images reconstructed in coronal, sagittal, and axial planes when integrated CT–positron emission tomography imaging was performed (n =

Comment

Results of this study show that ESS procedures improve the accuracy of MPM staging, and are important in determining appropriate therapy in patients being considered for extrapleural pneumonectomy. Specifically, extrapleural pneumonectomy was precluded because of positive findings at ESS in 15 of the 118 patients (12.7%). In this regard, laparoscopy was particularly useful in detecting unsuspected transdiaphragmatic extension of tumor. Although laparoscopy has been shown to improve staging

References (17)

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