title: The case for routine cervical mediastinoscopy prior to radical surgery for malignant pleural mesothelioma.
abstract: OBJECTIVE
  To assess whether cervical mediastinoscopy is necessary before radical resection of malignant pleural mesothelioma (MPM).
  
  
  METHODS
  Patients who underwent radical excision of MPM in a 48-month period were prospectively followed for evidence of disease recurrence and death. Histological evidence of extra pleural lymph node metastases was correlated with survival. Lymph node size at intraoperative lymphadenectomy was correlated with the presence of metastatic tumour.
  
  
  RESULTS
  The 55 patients who underwent radical resection (51 extra pleural pneumonectomies and 4 radical pleurectomies) comprised 50 men and 5 women with a median age of 58 years, range 41-70. Histological examination revealed 50 epithelioid, four biphasic and one sarcomatoid histology. Postoperative IMIG T stage was stage I 4, II 11, III 30 and IV 10. Postoperatively the 17 patients with metastases to the extra pleural lymph nodes had significantly shorter survival (median 4.4 months, 95% CI 3.2-5.4) than those without (median survival 16.3 months, 95% CI 11.6-21.0) P=0.012 Kaplan-Meier analysis. Seventy-seven extra pleural lymph nodes without metastases were measured with a mean long axis diameter of 16.9 mm (range 4-55); 22 positive nodes had a mean long axis diameter of 15.2 mm (range 6-30). In 15 of the 17 patients with positive extra pleural nodes, the nodes could have been biopsied at cervical mediastinoscopy.
  
  
  CONCLUSIONS
  This study confirms that extra pleural nodal metastases are related to poor survival. Pathological nodal involvement cannot be predicted from nodal dimensions. These data suggest that all patients being considered for radical resection of MPM should preferentially undergo preoperative cervical mediastinoscopy irrespective of radiological findings.
authors.affiliation: Department of Thoracic surgery, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK.
authors.forename: J E
authors.initials: JE
authors.lastname: Pilling
authors.forename: D J
authors.initials: DJ
authors.lastname: Stewart
authors.forename: A E
authors.initials: AE
authors.lastname: Martin-Ucar
authors.forename: S
authors.initials: S
authors.lastname: Muller
authors.forename: K J
authors.initials: KJ
authors.lastname: O'Byrne
authors.forename: D A
authors.initials: DA
authors.lastname: Waller
mesh_terms: D000328:Adult; D000368:Aged; D003955:Diagnostic Tests, Routine; D005260:Female; D006801:Humans; D008207:Lymphatic Metastasis; D008297:Male; D008481:Mediastinoscopy; D008654:Mesothelioma / Q000473:pathology / Q000556:secondary* / Q000601:surgery*; D008875:Middle Aged; D009333:Neck; D009367:Neoplasm Staging; D010997:Pleural Neoplasms / Q000473:pathology / Q000601:surgery*; D011300:Preoperative Care / Q000379:methods*; D011446:Prospective Studies; D016019:Survival Analysis