HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pilling, J.E. Articles by Waller, D.A. Search for Related Content PubMed PubMed Citation Articles by Pilling, J.E. Articles by Waller, D.A. Related Collections Mediastinum Pleura

Eur J Cardiothorac Surg 2004;25:497-501
© 2004 Elsevier Science NL

The case for routine cervical mediastinoscopy prior to radical surgery for malignant pleural mesothelioma

^a Department of Thoracic surgery, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
^b Department of Pathology, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
^c Department of Oncology, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK

Received 6 September 2003; received in revised form 25 November 2003; accepted 1 December 2003.

^* Corresponding author. Tel.: +44-116-256-3959; fax: +44-116-236-7768
e-mail: debra.grew{at}uhl-tr.nhs.uk

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
Objectives: 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.

Key Words: Malignant pleural mesothelioma • Staging • Thoracic surgery • Lymph nodes

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
The incidence of malignant pleural mesothelioma (MPM) by the most conservative estimate will rise to 1300 deaths per year by 2010 and cause the death of one in every 100 men born in the 1940s [1]. MPM has a poor prognosis with a median survival of 5.9 months from time of histological diagnosis [2]. Multimodality therapy, including radical surgical resection, offers the maximum reported survival with a small number of 5-year survivors [3]. It has been shown that patients with MPM and extra pleural lymph node metastases have a poor prognosis after surgery [4,5].

In the non-invasive assessment of mediastinal nodes in non-small cell lung cancer (NSCLC), nodes containing metastases are believed to be larger than those that do not and nodes with a short axis of 10 mm or long axis of 15 mm are believed to be positive [6]. We evaluated the size of lymph nodes in lymphadenectomy specimens from patients who underwent radical excision for MPM to assess whether nodal size is a predictor of metastatic involvement in MPM as it is considered to be in NSCLC.

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
2.1. Patients
Patients with biopsy proven MPM are referred to our centre from across the United Kingdom for consideration of radical surgery. Assessment began with a full history and clinical examination. Fitness for surgery was assessed according to the British Thoracic Society guidelines for pneumonectomy [7]. Pulmonary function assessment included predicted postoperative forced expiratory volume in one second (FEV₁): if the value achieved was less than 40% of predicted, extra pleuropneumonectomy (EPP) was excluded and radical pleurectomy was considered. Patients also underwent preoperative echocardiogram and patients with right ventricular dilatation and, or failure were excluded from radical surgery.

All patients had undergone CT scan of the thorax and upper abdomen before referral and these were assessed to determine resectability and mediastinal lymph node status. No patient had any clinical evidence of extra thoracic disease. Patients then proceeded to contrast enhanced magnetic resonance imaging of the thorax and upper abdomen as already described [8]. Resectability was defined by tumour confined to one hemithorax, with the absence of mediastinal organ or full-thickness pericardial/myocardial involvement, absence of diffuse or multifocal chest wall disease, transdiaphragmatic extension or spread directly into the spine, hence excluding stage T4 disease. Contrast enhancement of sites of previous entry to the chest were not, in themselves, seen as any contraindication to radical surgery, as these were widely excised. The single patient with enlarged mediastinal lymph nodes on CT scan underwent preoperative cervical mediastinoscopy which did not demonstrate malignancy. During the early part of this study fluorodeoxyglucose positron emission tomography (PET) scan was not available in Leicester and was not used in any of the patients in the latter part of the study as they had no symptoms of metastatic disease or evidence of upper abdominal spread on cross-sectional imaging.

Over a 48-month period 55 patients underwent radical excision of MPM in a single thoracic surgical practice. They comprised 50 men and 5 women, median age 58 years (range 41–70 years). They underwent four radical pleurectomies and 51 extra pleural pneumonectomies. Thirty-one patients underwent right-sided operations and 24 left. Fifty patients were found to have epithelioid MPM, four biphasic MPM and one sarcomatoid MPM. In all patients systematic mediastinal lymph node dissection was performed to allow accurate surgical staging of the disease. Nodes were sampled from station 7 and at least two other extra pleural stations in each patient. All macroscopically abnormal lymph nodes were cleared. All patients were prospectively followed for signs of recurrence and death. All patients were referred to an oncologist for consideration of adjuvant treatment. Postoperative survival was compared between those patients with and without extra pleural lymph node metastases.

2.2. Lymph node analysis
Postoperative pathological analysis had recorded the long axis diameter of 99ⁿ of the 436 lymph nodes excised at operation. These nodes had been fixed in 5% formaldehyde and then measured. The lymph nodes were then embedded in wax and sections performed through each lymph node. These were stained with haematoxylin and eosin before examination by light microscopy to determine the presence of metastatic tumour.

2.3. Statistical analysis
The long axis diameter of lymph nodes with or without metastatic involvement was compared by Student's t-test. Postoperative survival of the patients with or without extra pleural lymph node metastases was compared using Kaplan–Meier log rank analysis.

	3. Results

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
3.1. Postoperative survival
Of the 55 patients who underwent radical resection of MPM, 17 were found to have extra pleural lymph node metastases. The two groups are compared in Table 1. Fifteen patients (27.2%) had R1 resections on histological examination; one patient (1.8%) had an R2 resection.

The overall median survival of the patients was 12.5 postoperative months (95% confidence intervals (CI) 5.4–19.6 months). The median postoperative survival of those patients with extra pleural lymph node metastases was 4.4 months (95% CI 3.3–5.4 months) significantly less than those without extra pleural lymph node metastases which was 16.3 months (95% CI 11.6–21.0 months) P=0.012 on Kaplan–Meier log rank analysis, see Fig 1 .

View larger version (15K): [in this window] [in a new window]   Fig. 1. Kaplan–Meier plot of postoperative survival in days comparing patients with and without extra pleural lymph node metastases (P=0.012).

Thirty-five patients had extra pleural lymph nodes whose long axis was greater than 15 mm; only eight of them contained metastases on histological examination. Twenty patients had no lymph nodes with a long axis diameter less than 15 mm and of these nine had metastases to extra pleural nodes. Nodes were sampled from most of the Naruke extra pleural lymph node stations [9], see Fig. 2 .

View larger version (14K): [in this window] [in a new window]   Fig. 2. Histogram showing the number of nodes for which measurements were available by station and whether they were positive for metastatic deposit.

	4. Discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
Extra pleural lymph node metastases are common in patients presenting for consideration of radical surgery for MPM. Maggi et al. found that nine of the 32 (28%) patients who underwent surgery had positive mediastinal nodes [10]. Schouwink et al. found a positive mediastinal nodal rate of 33% after radical surgery [11], while Rusch et al. reported a rate of 82 in 157 patients (52%) [5] and Sugarbaker et al. found positive extra pleural nodes in 40 of 176 patients (23%) [3]. We report a series where 17 of 55 patients (31%) were found to have extra pleural lymph node metastases after radical resection.

We have shown in our study that extra pleural lymph node metastases are related to a significantly poorer prognosis after radical resection of MPM. This confirms the published findings of other groups [4,5]. In fact the patients with extra pleural lymph node disease who underwent radical resection have a similar survival to the series of patients diagnosed with MPM in Leicester between 1988 and 1998; only eight of 138 underwent radical surgery [2].

We have also shown that the long axis diameter of lymph nodes containing metastatic tumour is not significantly different from those free of tumour in patients with MPM. These findings are similar to those of Prenzel et al. who showed that lymph node size was not a reliable parameter for evaluation of metastatic involvement in NSCLC [12]. The long axis diameter of the mediastinal nodes free from metastatic involvement was significantly smaller than those involved (7.07 mm compared to 11.3 mm, P=0.005). Of all lymph nodes less than 10 mm in diameter 8.4% were involved with tumour and only 30% of those larger than 10 mm were involved.

Wathen et al. in their series investigating the role of CT in the preoperative assessment of NSCLC showed that lymph node size did not correlate with metastatic involvement and hence recommended that all mediastinal lymph nodes visualised on CT should be biopsied prior to pulmonary resection [13]. The Canadian Lung Oncology Group showed in their randomised control trial that reserving mediastinoscopy for patients with mediastinal lymph nodes greater than 10 mm on CT scan was as good as routine cervical mediastinoscopy [14].

As the size of lymph nodes is not significantly different if they are involved by metastatic MPM it must be the case that preoperative imaging using size criteria will be unreliable in staging extra pleural lymph node metastases in patients with MPM. Studies using CT to stage MPM nodal status have reported poor results with accuracy rates of 67% [11] and 75% [15].

The optimal role of cervical mediastinoscopy in the preoperative assessment of patients for radical resection of MPM remains to be determined. A recent study has shown cervical mediastinoscopy accurately staged extra pleural lymph node metastases in 93% of patients who went on to have radical resection of MPM [11]. In 14 of the 17 patients with extra pleural lymph node metastases in our series the positive nodes were accessible by cervical mediastinoscopy i.e. stations 2R, 4R, 7 and 2L. Schouwink et al. report that lymph nodes not accessible to mediastinoscopy were found to be positive in six of 25 patients who underwent thoracotomy and who previously had negative mediastinoscopy in their study [11]. Out of the 82 mediastinal nodal positive cases reported by Rusch et al. 41 had metastases to stations accessible to mediastinoscopy [5]. Of 32 patients who were surgically staged by Maggi et al. nine had extra pleural lymph node involvement, four of whom accessible by cervical mediastinoscopy [10]. Sugarbaker et al. reported 40 patients with extra pleural lymph node metastases in a series of 176 patients. In 11 of the positive patients the metastases were to peridiaphragmatic nodes [3].

There has been recent interest in PET to stage MPM and a number of series have been published. In their series of 18 patients who underwent PET scan Schneider et al. reported that four patients had extra pleural lymph nodes identified by PET and proven on surgical biopsy. The negative PET scan of the mediastinal nodes was confirmed by surgical biopsy in 12 of the remaining 14 patients [16]. Bernard et al.'s series of 28 patients with suspected MPM showed PET scan positive mediastinal nodes in 12 patients; CT scan showed normal size nodes in nine patients. Biopsies were taken in six cases confirming metastases in five and granulomatous lymphadenitis in one. Of the 12 patients with a negative PET scan of their mediastinal nodes four had biopsies, three were negative and one positive for metastatic involvement [17]. Flores et al. showed that of 31 surgical staged patients, who underwent preoperative PET scan, nine had mediastinal nodal involvement but PET scan correctly identified only one of these [18].

We conclude that extra pleural lymph node metastases are a contraindication to radical resection of MPM. Imaging must be an unreliable method for assessing metastases from MPM to the extra pleural lymph nodes as the size of involved and uninvolved nodes are not significantly different and although PET scan has not rigorously tested it has been shown to assess the mediastinum inaccurately [18]. Cervical mediastinoscopy should be performed to accurately stage the patient's disease before offering radical tumour excision.

	Footnotes

 
Presented at the joint 17th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 11th Annual Meeting of the European Society of Thoracic Surgeons, Vienna, Austria, October 12–15, 2003.

	Appendix A. Conference discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
Dr M.U. Rehman (Cottingham, United Kingdom): I think it was very clear from Sugarbaker's study that lymph node status does influence the outcome and that he has reported in his classification that if you have lymph nodes or not, you don't go to a radical surgery for mesothelioma. Contrary to that, in a 10-year study which came out a couple of years ago, Aziz presented that lymph node status has no implication at all. So how do you compare your results with that small group compared to these two big studies, please?

Dr Pilling: Well, our findings agree with Sugarbaker's findings that extra pleural lymph node metastases do affect survival after operation, and therefore we would view them as a contraindication to proceeding to radical surgery. The issue in this presentation is the fact that you cannot stage them accurately preoperatively with imaging because the size of the lymph nodes are not affected by whether they are involved in the metastases or not.

Dr H. Hansen (Copenhagen, Denmark): Does your study not show the necessity of a PET/CT scan to image your lymph nodes?

Dr Pilling: We don't use PET on our patients for mesothelioma at the present time in Leicester, but there has been a recent paper by Valerie Rusch and colleagues who looked at 31 patients with surgically-proven nodal disease. Nine had N2 disease, but only one was correctly identified on PET scan preoperatively. And I think certainly PET scan on its own is inaccurate in staging mediastinal involvement. Whether CT/PET would be better, I don't know. I don't know of any data on that.

Dr S. Halezeroglu (Istanbul, Turkey): I'm very surprised to see that if one patient has N2 disease, this patient will die within 4 months of the operation. This is very surprising to me. And I know that no patient will die of N2 disease itself, because if one patient has N2 disease, this means that this patient has another distant metastasis and this will cause the death of this patient, and if you consider that these patients will be dying of distant metastasis but not the N2 disease itself, do you consider that these patients had distant metastasis during the operation?

Dr Pilling: No, I think we have made a reasonable search for distant metastases, including history, clinical examination and CT and MRI scan of the thorax and the upper abdomen. I'm not saying that they all died by 4 months after the operation. I'm saying their median survival is 4 months after the operation. So there are some that survive longer, but N2 disease does statistically predict a worse outcome.

Dr E. Ruffini (Chieri, Italy): I'm speaking on behalf of Professor Maggi.

I see in your series that half of your patients had metastases on the subcarinal nodes. How reliable could mediastinoscopy be in detecting level No. 7 metastases? This is quite a difficult station to pick up, especially when the mediastinal pleura is involved.

Dr Pilling: Absolutely. We have only just started to perform cervical mediastinoscopy. We have done 4 patients now. So we will be able to report our experience in due course. There was a paper by Schouwink in the Annals of Thoracic Surgery this year that reported a 93% accuracy rate for cervical mediastinoscopy in N2 disease in malignant pleural mesothelioma. They found that positive nodes were found after a negative cervical mediastinoscopy in 6 of the 25 patients that they studied. So it will miss some patients. We think 88% would be accessible. So I think this is a tool which will allow us to avoid a hazardous operation on patients who probably shouldn't have it.

	References

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 

1. Peto J., Hodgson J., Matthews F., Jones J. Continuing increase in mesothelioma meortality in Britain. Lancet 1995;345:535-539.[CrossRef][Medline]
2. Edwards J., Abrams K., Leverment J., Spyt T., Waller D., O'Byrne K. Prognostic factors for malignant mesothelioma in 142 patients: validation of CALGB and EORTC prognostic scoring systmens. Thorax 2000;55:731-735.[Abstract/Free Full Text]
3. Sugarbaker D., Flores R., Jaklitsch M., Riachards W., Strauss G., Corson J., DeCamp M., Swanson S., Bueno R., Lukanich J., Baldini E., Mentzer S. Resection margins, extrapleural nodal status and cell type determine postoperative long term survival in trimodality therapy of malignant pleural mesothelioma: Results in 183 patients. J Thorac Cardiovasc Surg 1999;117:54-65.[Abstract/Free Full Text]
4. Sugarbaker D., Strauss G., Lynch T., Richards W., Mentzer S., Lee T., Corson J. Antman K node status has prognostic significance in the multi modality therapy of diffuse, malignant mesothelioma. J Clin Oncol 1993;11:1172-1178.[Abstract/Free Full Text]
5. Rusch V., Venkatraman E. Important prognostic factors in patients with malignant pleural mesothelioma, managed surgically. Ann Thorac Surg 1999;68:1799-1804.[Abstract/Free Full Text]
6. The American Thoracic Society and the European Respiratory Society. Pretreatment evaluation of non-small cell lung cancer. Am J Respir Crit Care Med 1997;156:320-332.[Free Full Text]
7. BTS guidelines. Guidelines on the selection of patients with lung cancer for surgery. Thorax 2001;56(2):89-108.[Free Full Text]
8. Stewart D.J., Waller D.A., Edwards J.G., Jeyapalan K., Entwisle J.J. Is there a role for pre-operative contrast-enhanced magnetic resonance imaging for radical surgery in malignant pleural mesothelioma?. Eur J Cardiothorac Surg 2003;24:1019-1024.[Abstract/Free Full Text]
9. Naruke T., Suemasu K., Ishikawa S. Lymph node mapping and curability at various levels of metastasis in resected lung cancer. J Thorac Cardiovasc Surg 1978;79:832-839.
10. Maggi G., Casadio C., Cianci R., Rena O., Ruffini E. Trimodality management of malignant pleural mesothelioma. Eur J Cardiothorac Surg 2001;19:346-350.[Abstract/Free Full Text]
11. Schouwink J., Kool L., Rutgers E., Zoetmulder F., Zandwijk N., Vijver M., Baas P. The value of chest computer tomography and cervical mediastinoscopy in the preoperative assessment of patients with malignant pleural mesothelioma. Ann Thorac Surg 2003;75:1715-1719.[Abstract/Free Full Text]
12. Prenzel K., Monig S., Sinning J., Baldus S., Brochhagen H., Schneider P., Holscher A. Lymph node size and metastatic infiltration in non-small cell lung cancer. Chest 2003;123:463-467.[Abstract/Free Full Text]
13. Wathen C., Kerr K., Reid W., Wightman A., Best J., Millar A., Walker W., Cameron E., Douglas N. A comparison of cobalt bleomycin scanning and contrast enhanced CT scanning for assessment of the mediastinum in lung cancer. Chest 1990;97:1148-1151.[Abstract/Free Full Text]
14. The Canadian Lung Oncolgy Group. Investigatiopn for mediastinal disease in patients with apparently operable lung cancer. Ann Thorac Surg 1995;60:1382-1389.[Abstract/Free Full Text]
15. Rusch V., Godwin J., Shuman W. The role of computed tomography scanning in the initial assessment and the follow up of malignant pleural mesothalioma. J Thorac Cardiovasc Surg 1988;96:171-177.[Abstract]
16. Venissac N., Alifano M., Mouroux J. Video-assisted mediastinoscopy: experience from 240 consecutive cases. Ann Thorac Surg 2003;76:208-212.[Abstract/Free Full Text]
17. Benard F., Sterman D., Smith R., Kaiser L., Albeda S., Alavi A. Metabolic imaging of malignant pleural mesothelioma with fluorodeoxyglucose positron emission tomography. Chest 1998;114:713-722.[Abstract/Free Full Text]
18. Flores R.M., Akhurst T., Gonen M., Larson S.M., Rusch V.W. Positron emission tomography defines metastatic disease but not locoregional disease in patients with malignant pleural mesothelioma. J Thorac Cardiovasc Surg 2003;126(1):11-16.[Abstract/Free Full Text]
19. Rusch V., Venkatraman E. The importance of surgical staging in the treatment of malignant pleural mesothelioma. J Thorac Cardiovasc Surg 1996;111:815-826.[Abstract/Free Full Text]

This article has been cited by other articles:

				M. H. Chamberlain, K. Fareed, A. Nakas, A. E. Martin-Ucar, and D. A. Waller Video-assisted cervical thoracoscopy: a novel approach for diagnosis, staging and pleurodesis of malignant pleural mesothelioma. Eur. J. Cardiothorac. Surg., July 1, 2008; 34(1): 200 - 203. [Abstract] [Full Text] [PDF]

				T. C. Mineo, V. Ambrogi, E. Pompeo, A. Baldi, F. Stella, P. Aurea, and M. Marino The value of occult disease in resection margin and lymph node after extrapleural pneumonectomy for malignant mesothelioma. Ann. Thorac. Surg., May 1, 2008; 85(5): 1740 - 1746. [Abstract] [Full Text] [PDF]

				A. Nakas, A. E. Martin Ucar, J. G. Edwards, and D. A. Waller The role of video assisted thoracoscopic pleurectomy/decortication in the therapeutic management of malignant pleural mesothelioma Eur. J. Cardiothorac. Surg., January 1, 2008; 33(1): 83 - 88. [Abstract] [Full Text] [PDF]

				J. G. Edwards, A. E. Martin-Ucar, D. J. Stewart, and D. A. Waller Right extrapleural pneumonectomy for malignant mesothelioma via median sternotomy or thoracotomy?: Short- and long-term results Eur. J. Cardiothorac. Surg., May 1, 2007; 31(5): 759 - 764. [Abstract] [Full Text] [PDF]

				A. E. Martin-Ucar, A. Nakas, J. G. Edwards, and D. A. Waller Case-control study between extrapleural pneumonectomy and radical pleurectomy/decortication for pathological N2 malignant pleural mesothelioma Eur. J. Cardiothorac. Surg., May 1, 2007; 31(5): 765 - 770. [Abstract] [Full Text] [PDF]

				M. de Perrot, K. Uy, M. Anraku, M. S. Tsao, G. Darling, T. K. Waddell, A. F. Pierre, A. Bezjak, S. Keshavjee, and M. R. Johnston Impact of lymph node metastasis on outcome after extrapleural pneumonectomy for malignant pleural mesothelioma J. Thorac. Cardiovasc. Surg., January 1, 2007; 133(1): 111 - 116. [Abstract] [Full Text] [PDF]

				P. S. Adusumilli, D. P. Eisenberg, B. M. Stiles, S. Chung, M.-K. Chan, V. W. Rusch, and Y. Fong Intraoperative localization of lymph node metastases with a replication-competent herpes simplex virus. J. Thorac. Cardiovasc. Surg., November 1, 2006; 132(5): 1179 - 1188. [Abstract] [Full Text] [PDF]

				C. P Clarke, S. R Knight, F. J Daniel, and S. Seevanayagam Management of Malignant Mesothelioma by Decortication and Adjunct Phototherapy Asian Cardiovasc Thorac Ann, June 1, 2006; 14(3): 206 - 209. [Abstract] [Full Text] [PDF]

				J. G. Edwards, D.J. Stewart, A. Martin-Ucar, S. Muller, C. Richards, and D. A. Waller The pattern of lymph node involvement influences outcome after extrapleural pneumonectomy for malignant mesothelioma J. Thorac. Cardiovasc. Surg., May 1, 2006; 131(5): 981 - 987. [Abstract] [Full Text] [PDF]

				A. E. Martin-Ucar, D. J. Stewart, K. J. West, and D. A. Waller A Median Sternotomy Approach to Right Extrapleural Pneumonectomy for Mesothelioma Ann. Thorac. Surg., September 1, 2005; 80(3): 1143 - 1145. [Abstract] [Full Text] [PDF]

				D. J. Stewart, A. E. Martin-Ucar, J. G. Edwards, K. West, and D. A. Waller Extra-pleural pneumonectomy for malignant pleural mesothelioma: the risks of induction chemotherapy, right-sided procedures and prolonged operations Eur. J. Cardiothorac. Surg., March 1, 2005; 27(3): 373 - 378. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pilling, J.E. Articles by Waller, D.A. Search for Related Content PubMed PubMed Citation Articles by Pilling, J.E. Articles by Waller, D.A. Related Collections Mediastinum Pleura