PURPOSE: The purpose of this study was to determine if invasive staging procedures altered the management of patients with pleural mesothelioma.
METHODS: 52 patients with pleural mesothelioma were evaluated for candidacy in a surgery based multimodal treatment protocol.. All patients had radiographic staging workups including, chest and abdominal CT scans and head CT or MRI. 6 patients were excluded for either medical reasons or radiographically detected metastases. 46 patients went on to have an invasive staging procedure, performed on an outpatient basis with no morbidity or mortality. The “staging procedure” included a bronchoscopy, esophagogastroduodenoscopy and laparoscopy with peritoneal lavage for cytologic evaluation.
RESULTS: Four patients were found to have metastatic disease at laparoscopy. Three patients were found to have visible nodules (measuring only 1-2 mm) and one patient had a peritoneal lavage that revealed tumor cells in the absence of any visible disease. One of the 3 patients with visible nodules had a negative peritoneal lavage. One patient was found to have a contralateral endobronchial metastasis (2 mm) and one patient had contralateral distal pulmonary disease identified on cytology from a bronchial lavage. One patient had a biopsy proven isolated skin metastasis and another had positive cytology on a contralateral thoracentesis. None of these lesions were identified as metastatic disease on the preoperative radiographic studies.
CONCLUSION: On invasive staging, 8 patients (17%) were found to have unsuspected metastatic disease, of which 50% were identified by laparoscopy and 25% by bronchoscopy. Esophagoscopy failed to reveal any direct tumor extension or occult metastases.
CLINICAL IMPLICATIONS: Currently there is no role for an aggressive surgical procedure for a patient with pleural mesothelioma that has spread beyond the affected hemithorax. Consequently, when contemplating surgical intervention for a patient with mesothelioma, we feel that bronchoscopy and laparoscopy are mandatory components of the preoperative staging and can be performed safely on an outpatient basis.
DISCLOSURE: Joseph Friedberg, None.