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The Case for Routine Mediastinoscopy Prior To Radical Resection of Malignant Pleural Mesothelioma

Glenfield Hospital, Leicester, United Kingdom

PURPOSE: To assess whether cervical mediastinoscopy is mandatory before radical resection of malignant pleural mesothelioma (MPM).

METHODS: 46 patients who underwent radical excision of MPM between August 1999 and April 2003 were prospectively followed. Pre operative contrast enhanced magnetic resonance imaging (CEMRI) stage, tumour stage, long axis of lymph nodes and presence of metastatic tumour were collected. Pre operative CEMRI stage was compared with histological stage to generate sensitivity and specificity for nodal staging. The long axis measurements of lymph nodes in 42 patients’ pathological specimens were compared with the presence of tumour.

RESULTS: 46 patients (6 women, 40 men, median age 58 years, range 41 – 70) underwent 3 radical pleurectomies and 43 extrapleural pneumonectomies. Comparison of the postoperative survival of N0/1 with N2 disease is shown in the table.

Comparison of N0/1 and N2 patients Nodal Stage N0/1 N2 n 34 12 Age (years) median 57 61 NS range 41 - 70 41 - 68 Post operative survival (days) median 417 135 p=0.03 95% confidence interval 292 - 542 103 - 167 T stage (TMN classification) I 2 0 II 22 6 III 10 3 IV 1 3

62 negative lymph nodes were measured and had a mean long axis of 16.2 mm (median 15, range 4 - 47) compared to 19 positive lymph nodes whose mean long axis was 14.4 mm (median 12, range 7 - 30) [p=0.20].

CEMRI was performed a median 16 days pre operatively (range 1 - 53). CEMRI sensitivity for nodal disease is (4/19) 21% and specificity (23/26) 88%.

CONCLUSIONS: In MPM N2 disease is related to poor survival compared with N1/0 disease. Preoperative staging by CEMRI differentiates poorly between nodal stages. Pathological nodal involvement cannot be predicted from nodal dimensions.

CLINICAL IMPLICATIONS: These data suggest all patients considered for radical resection of MPM should undergo cervical mediastinoscopy.

DISCLOSURE: J. Pilling, None.