Diagnostic Laparoscopy Improves Staging of Malignant Pleural Mesothelioma with Routine PET Imaging

Annals of Thoracic Surgery 2020 December 1 [Link]

R Taylor Ripley, Nihanth Palivela, Shawn S Groth, Eugene A Choi, Lorraine D Cornwell, Phillip W Carrott, George Van Buren, Taylor G Splawn, David J Sugarbaker, Bryan M Burt


Background: With a multimodal treatment strategy, cytoreductive surgery extends survival in malignant pleural mesothelioma. Improving the accuracy of staging can refine patient selection. Our objective was to determine whether diagnostic laparoscopy (DL) improves staging for patients with malignant pleural mesothelioma with routine use of positron emission tomography.

Methods: We performed a retrospective review of our prospectively maintained database from February 2014 until May 2019. Inclusion criteria were patients who had disease in the chest that was deemed potentially resectable by radiographic criteria and who underwent DL as part of staging evaluation prior to surgery.

Results: 187 patients (71% male, 80% epithelial) underwent DL during staging. 76% proceeded to surgery. 22% were unresectable at exploratory thoracotomy and 78% underwent resection (Pleurectomy and decortication, 68%; extrapleural pneumonectomy, 32%). 89% had a position-emission tomography-computed tomographic scan (PET-CT) and 11% had a pre-operative CT without PET. DL revealed peritoneal disease in 17%. Among patients with pathologically proven disease at DL, 77% had negative PET-CT imaging. Based upon the pathologic findings at DL, the sensitivity, specificity, positive predictive value, and negative predictive value of PET-CT were 23%, 78%, 17%, and 83%, respectively. The accuracy of PET-CT was 68%.

Conclusions: PET-CT has low sensitivity and diagnostic accuracy to identify peritoneal disease in malignant pleural mesothelioma. DL as part of pre-operative staging defines an important subset of patients with bicavitary disease. We recommend DL as a component of staging prior to surgery.