Staging algorithm for diffuse malignant pleural mesothelioma☆

Abstract

An algorithm of preoperative mediastinal nodal staging with endobronchial/endoesophageal ultrasonography (EBUS/EUS) and transcervical extended mediastinal lymphadenectomy (TEMLA) combined with laparoscopy/peritoneal lavage and cytology was analyzed to establish the realistic criteria for radical multimodality treatment of malignant pleural mesothelioma (MPM). The algorithm included computed tomography (CT), thoracoscopy with multiple pleural biopsies and talc pleurodesis, EBUS/EUS and one-stage TEMLA and laparoscopy/peritoneal lavage and cytology of the fluid. Forty-two patients were diagnosed from 1 January 2004 to 31 December 2008. There were 16 women and 26 men in ages ranging from 43 to 77 years (mean 57.8); 31 epithelioid, 2 sarcomatoid and 9 biphasic type MPM. 21/42 patients were considered possible candidates for multimodality treatment. Three patients who received neoadjuvant chemotherapy were excluded from this study. EBUS/EUS was performed to stage the mediastinal nodes. In 3/18 patients metastatic nodes were discovered. In the rest of the 15 patients simultaneous TEMLA and laparoscopy/peritoneal lavage and cytology of the fluid were performed. In three patients TEMLA was positive, in six patients laparoscopy was positive and in two patients both TEMLA and laparoscopy were positive. Finally, 4/42 (9.5%) patients underwent thoracotomy with one exploration (chest wall infiltration) and three pleuropneumonectomies with the subsequent chemo- and radiotherapy. The proposed algorithm of preoperative staging spared the majority of MPM patients from futile surgery.

The role of endobronchial ultrasound-guided fine needle aspiration in the diagnosis of pleural mesothelioma

“…They proposed a detailed algorithm for the nodal assessment of patients with a diagnosis of MPM. When the result of the EBUS‐TBNA is negative, the nodal staging should be achieved by transcervical extended mediastinal lymphadenectomy (TEMLA) . Currently, there is little agreement regarding standards of care of MPM.…”

Extrapleural Pneumonectomy in the Treatment of Epithelioid Malignant Pleural Mesothelioma

“…However, given the inaccessibility of relevant nodal stations, it is reasonable to consider whether endoscopic ultrasonography, endobronchial ultrasonography, thoracoscopy, or other procedures should be routinely performed as part of a surgical staging strategy. 18,19 …”

The role of thoracic surgery in the management of mesothelioma: an expert opinion on the limited evidence

“…There is some evidence for more aggressive algorithms of preoperative surgical staging using laparoscopic lavage to discover unknown diaphragmatic invasion despite no macroscopic signs of infiltration of the diaphragm; Zelinski [27] and Rice [22] advocated a better sensitivity of the peritoneal lavage compared with CT scan in detecting diaphragm invasion. The presence of occult peritoneal metastases in the absence of mediastinal node involvement remains to be established.…”