The new case for cervical mediastinoscopy in selection for radical surgery for malignant pleural mesothelioma

Our plain-English summary of The new case for cervical mediastinoscopy in selection for radical surgery for malignant pleural mesothelioma, by A. Nakas, D. Waller, K. Lau, et al (European Journal of Cardio-thoracic Surgery, 2012).

The study

• Authors: A. Nakas, D. Waller, K. Lau, C. Richards, S. Muller
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2012;42(1):72-6; discussion 76
• Cited by: 21 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objectives: Selection criteria for radical surgery in malignant pleural mesothelioma (MPM) and related clinical trials remain controversial. The relative importance of nodal metastases and the need for pre-operative nodal staging are undetermined.

Methods: From a prospective database, we identified 212 patients with non-sarcomatoid MPM (160 epithelioid and 52 biphasic). A total of 127 patients underwent extrapleural pneumonectoctomy (EPP) and 85 lung-sparing total pleurectomy (LSTP) with lymphadenectomy. We investigated the effect of nodal burden and distribution in survival by testing for differences between N0, N1 and N2 disease and constructing a theoretical model dividing the patients into four groups according to diseased nodes identified in the surgical specimen: Group 0, no nodal disease; Group CM, nodes accessible by cervical mediastinoscopy (CM): Stations 2, 3a, 4 and 7; Group EBUS/EUS, nodes accessible by endobronchial (EBUS) or endoscopic (EUS) ultrasound: Stations 2, 3a, 4 and 7-11. Group EM, extramediastinal nodes not accessible by CM or EBUS/EUS: Stations 5, 6, internal mammary, pericardial and diaphragmatic lymph nodes.

Results: There was no difference in overall median survival between EPP and LSTP [15.6, SE 1.8, 95% confidence interval (CI) 12-19 months versus 13.4, SE 2.3, 95% CI 9-18 months, P=0.41]. Patients with N0 disease (n=94) had the best prognosis: median survival was 19.6 months (SE 3, 95% CI 13.2-26) versus 12 months for the 19 patients with N1 (SE 1.5, 95% CI 9-15) and 13.6 months for 99 patients with N2 (SE 1.7, 95% CI 10-17), P=0.015. Subgroup analysis of patients with nodal metastases revealed no significant survival difference between group CM and group EBUS/EUS: achieving maximum theoretical diagnostic yield CM could detect 63 (54%) of patients with nodal disease and the median survival of this group was 13.6 months (SE 2, 95% CI 9.6-17.6). EBUS/EUS could detect an additional 30 cases (26%) with survival of 11.3 months (SE 1, 95% CI 9-13.6). The survival in group EM (25 cases, 21%, median survival 18.7 months, SE 6, 95% CI 7-30) was significantly better than groups CM or EBUS/EUS, P=0.002.

Conclusions: There is a strong case for routine CM as a method of prognostic staging in all patients undergoing radical surgery for MPM. The addition of EUS staging and the detection of nodal metastases inaccessible to mediastinoscopy had no prognostic benefit.

In plain English

This study reviewed 212 patients with non-sarcomatoid malignant pleural mesothelioma (160 epithelioid, 52 biphasic) who had radical surgery: 127 extrapleural pneumonectomy, 85 lung-sparing total pleurectomy. Based on diseased nodes in the removed tissue, the authors grouped patients by which pre-operative test could theoretically reach them, assuming 100% accuracy. Median survival was 19.6 months (95% CI 13.2 to 26) for 94 patients without node involvement, 12 months (95% CI 9 to 15) for 19 with N1 and 13.6 months (95% CI 10 to 17) for 99 with N2 disease. It was 13.6 months (95% CI 9.6 to 17.6) for 63 patients whose nodes cervical mediastinoscopy could reach and 11.3 months (95% CI 9 to 13.6) for 30 reachable only by ultrasound methods (P = 0.69, not statistically significant). The 25 whose diseased nodes none of these tests could reach survived a median of 18.7 months (95% CI 7.5 to 29.8), significantly longer than those two groups combined (P = 0.022). The authors concluded there is a strong case for routine cervical mediastinoscopy before radical surgery. The article does not report asbestos exposure.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective analysis of a single-institution surgical database, using a theoretical model of pre-operative lymph node staging
• Who was studied: 212 patients with non-sarcomatoid malignant pleural mesothelioma who underwent radical surgery over 12 years at Glenfield Hospital, Leicester, UK.
• Sex: 181 males, 31 females.
• Age: median 59 (range 14 to 72).
• Operation: 127 had extrapleural pneumonectomy (EPP) and 85 had lung-sparing total pleurectomy (LSTP).
• Tumour type: 160 (75%) epithelioid and 52 (25%) biphasic.
• Exposure: The article does not report asbestos exposure. The factors studied were:
• lymph node involvement in the surgical specimen, grouped by nodal stage (N0, N1, N2);
• which staging test could theoretically reach the involved nodes (cervical mediastinoscopy, EBUS/EUS, or neither);
• the type of operation.
• Main results:
  • There was no difference in median survival between EPP (15.6 months, 95% CI 12 to 19) and LSTP (13.4 months, 95% CI 9 to 18), P = 0.41.
  • Median survival by nodal stage, P = 0.015:
• pN0 (n = 94): 19.6 months (95% CI 13.2 to 26).
• pN1 (n = 19): 12 months (95% CI 9 to 15).
• pN2 (n = 99): 13.6 months (95% CI 10 to 17).
  • Of the 118 patients with positive lymph nodes:
• 63 had nodes in stations accessible by cervical mediastinoscopy (group CM).
• 30 had nodes accessible only by EBUS/EUS.
• 25 had nodes inaccessible by CM, EBUS or EUS (group EM: stations 5, 6, internal mammary, pericardial or paradiaphragmatic nodes).
  • Median survival was 13.6 months (95% CI 9.6 to 17.6) in group CM and 11.3 months (95% CI 9 to 13.6) in group EBUS/EUS. The difference was not statistically significant, P = 0.69.
  • Group EM (n = 25) had a median survival of 18.7 months (95% CI 7.5 to 29.8, Table 2). This was significantly better than groups CM and EBUS/EUS pooled together (median 12.4 months, 95% CI 9.8 to 15), P = 0.022.
  • Group N0 had significantly better survival than groups CM and EBUS/EUS, but not group EM, P = 0.002.
  • Patients with epithelioid mesothelioma survived significantly longer (median 19.1 months) than those with biphasic mesothelioma (median 11.4 months).
  • Twelve patients (5.7%) died within 30 days of surgery and 30 (14%) within 90 days.
• The authors' conclusion: The authors concluded there is a strong case for routine cervical mediastinoscopy as prognostic staging in all patients undergoing radical surgery for malignant pleural mesothelioma. They also concluded that adding EUS staging, and detecting nodal metastases inaccessible to mediastinoscopy, had no prognostic benefit.
• Limitations the authors state:
  • In LSTP, not all N1 lymph node stations may have been sampled.
  • N2 node interpretation may have been less reliable after LSTP than after EPP, possibly underestimating nodal spread.
  • In 23 cases (10.8%), fewer than four lymph nodes were identified in the surgical specimen.
  • The model assumed each staging method was 100% accurate, which the authors knew is not the case in practice.
  • The study was a theoretical construct. It did not account for availability, sensitivity, specificity, morbidity, mortality, costs and other factors.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Mediastinoscopy, Pleural Mesothelioma, Clinical Trial, Staging, Sarcomatoid, Epithelioid, Biphasic Mesothelioma, Ultrasound.

Related studies

• The management of the diaphragm during radical surgery for malignant pleural mesothelioma — A.J. Sharkey, R. Bilancia, et al. (2016)
• Predictors of long-term survival following radical surgery for malignant pleural mesothelioma — A. Nakas, D. Waller (2014)
• Surgery as part of radical treatment for malignant pleural mesothelioma — D.A. Waller, S. Tenconi (2017)
• How does the timing of chemotherapy affect outcome following radical surgery for malignant pleural mesothelioma? — A.J. Sharkey, K.J. O'Byrne, et al. (2016)
• Surgery in the treatment of malignant pleural mesothelioma: recruitment into trials should be the default position — A. Datta, R. Smith, et al. (2014)
• Long-term survival after lung-sparing total pleurectomy for locally advanced (International Mesothelioma Interest Group Stage T3-T4) non-sarcomatoid malignant pleural mesothelioma — A. Nakas, E. von Meyenfeldt, et al. (2012)

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