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J Thorac Cardiovasc Surg 2005;130:905-906
© 2005 The American Association for Thoracic Surgery
Brief Communication |
a Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Perth, Australia
b Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
c Department of Nuclear Medicine, Sir Charles Gairdner Hospital, Perth, Australia
d Department of Radiology, Sir Charles Gairdner Hospital, Perth, Australia
e Department of Oncology, Sir Charles Gairdner Hospital, Perth, Australia
Received for publication December 22, 2004; accepted for publication February 8, 2005. * Address for reprints: J. M. Alvarez, FRACS, Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands 6009, Perth, West Australia, Australia.
For selected patients with malignant mesothelioma, treatment with extrapleural pneumonectomy (EPP), chemotherapy, and hemithoracic irradiation (trimodality therapy) appears to confer improved survival relative to other treatment options.
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Sugarbaker and colleagues
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demonstrated a 5-year survival of 46%, with a median survival of 51 months, for patients with epithelial histologic type, negative extrapleural nodes, and negative resection margins. We therefore offer trimodality therapy to selected patients with stage 1 (limited to one hemithorax) epithelial malignant mesothelioma. All patients have preoperative computed tomographic (CT), magnetic resonance imaging (MRI), and positron emission tomographic (PET) scans.
1,2
However, EPP is only offered to those with histologically confirmed negative results of biopsy examinations of the mediastinum, contralateral pleura, and diaphragmatic peritoneum.
Clinical Summary
A 67-year-old woman was incidentally discovered to have a right pleural effusion. Cytologic examination confirmed malignant mesothelioma. CT, MRI, and PET scans (Figure 1, A-C), demonstrated stage 1 disease. The patient met established criteria for trimodality therapy.
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Discussion
The optimal management of stage 1 malignant mesothelioma is unclear. EPP is an operation associated with significant mortality (10%-30%) and morbidity. Sugarbaker and colleagues
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have reduced perioperative mortality for EPP to 5% with trimodality therapy and have reported unequalled survival in selected cases of malignant mesothelioma.
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Patterns of tumor recurrence after trimodality therapy reveal that 26% recur in the peritoneum. Conventional wisdom suggests the mechanism may relate to peritoneal seeding during surgery. However, 17% of malignant mesothelioma recurrences are in the contralateral pleura, and importantly, distant metastases are rare.
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This suggests that preoperative understaging may actually have occurred. Because of the significant morbidity associated with this radical protocol, the finite sensitivities of current imaging modalities, and the intimate (<1 mm) anatomic relations of both parietal pleura, the mediastinum, and peritoneum, we advocate bilateral thoracoscopy, mediastinoscopy, and laparoscopy, with respective biopsy samples, as integral to correctly staging malignant mesothelioma.
This case is important because it emphasizes that surgical preoperative staging appears necessary to prevent radical treatment of patients who would not actually benefit and that current nonsurgical staging procedures are not yet sufficiently sensitive to replace surgical staging. The sensitivity of noninvasive imaging is limited in low-volume or micrometastatic disease. State-of-the-art multislice CT, MRI, and PET scans were unable to detect transdiaphragmatic or contralateral pleural disease, and the pleura even appeared normal on visual inspection at thoracoscopy.
We offer trimodality therapy only to patients with epithelial histologic type. Surgical pleural biopsy is thus needed. Unilateral thoracoscopy, mediastinoscopy, and laparoscopy and contralateral thoracoscopy are performed. Operating time approaches 1 hour. Potential morbidity from these additional procedures appears justified by the profound impact that a positive result confers on treatment and prognosis. Our findings are important not only to centers offering trimodality therapy but also for staging malignant mesothelioma in general. Incorrect staging will invalidate trimodality therapy and subject patients to unnecessary, painful, and potentially harmful complications. Correct staging can only be achieved by a protocol that includes mediastinoscopy, laparoscopy, and bilateral thoracoscopy.
References
This article has been cited by other articles:
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  J. B. Sorensen, J. Ravn, A. Loft, J. Brenoe, A. K. Berthelsen, and on behalf of the Nordic Mesothelioma Group Preoperative staging of mesothelioma by 18F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography fused imaging and mediastinoscopy compared to pathological findings after extrapleural pneumonectomy Eur. J. Cardiothorac. Surg., November 1, 2008; 34(5): 1090 - 1096. [Abstract] [Full Text] [PDF]
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P. S. Adusumilli, D. P. Eisenberg, B. M. Stiles, S. Chung, M.-K. Chan, V. W. Rusch, and Y. Fong Intraoperative localization of lymph node metastases with a replication-competent herpes simplex virus. J. Thorac. Cardiovasc. Surg., November 1, 2006; 132(5): 1179 - 1188. [Abstract] [Full Text] [PDF]
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