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Eur J Cardiothorac Surg 2007;31:759-764. doi:10.1016/j.ejcts.2007.01.061
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Right extrapleural pneumonectomy for malignant mesothelioma via median sternotomy or thoracotomy?

Short- and long-term results

John G. Edwards, Antonio E. Martin-Ucar, Duncan J. Stewart, David A. Waller*

Department of Thoracic Surgery, Glenfield Hospital, Leicester, United Kingdom

Received 12 September 2006; received in revised form 31 December 2006; accepted 15 January 2007.

* Corresponding author. Address: Department of Thoracic Surgery, University Hospitals Leicester NHS Trust, Glenfield Hospital, Groby Road, Leicester LE3 9QP, United Kingdom. Tel.: +44 116 256 3959; fax: +44 116 236 7768. (Email: david.waller{at}uhl-tr.nhs.uk).


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
 References
 
Objective: To examine the short- and long-term results of right extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MM) via median sternotomy or thoracotomy. Methods: We analysed the results of EPP in consecutive patients with early stage MM undergoing a radical surgery protocol for MM over a 7-year period. Initially thoracotomy, but later median sternotomy, was the incision of choice for right-sided tumours. The effects of the change of approach on perioperative course and survival were analysed. Results: EPP was performed in 105 patients (50 left thoracotomy, 22 right thoracotomy, 28 sternotomy, 5 combined sternotomy and right thoracotomy). Operation time was faster with median sternotomy than right thoracotomy (p = 0.008). Right thoracotomy was associated with higher epidural infusion volume in the first 3 days than median sternotomy (p < 0.001). There were fewer postoperative complications in the sternotomy group (p = 0.05). There were no differences in pathological stage, completeness of resection or duration of postoperative stay. Median survival following left thoracotomy, right thoracotomy and median sternotomy was 18.3, 8.5 and 17.7 months, respectively (p = 0.02). Planned neoadjuvant or adjuvant chemotherapy was more common following median sternotomy than right thoracotomy (p = 0.01). However, compared with the left thoracotomy and sternotomy groups, right EPP performed via thoracotomy was an independent predictor of poor prognosis (hazard ratio 2.3 (95% confidence intervals, CI 1.3–4.1), p = 0.02). No wound complications or tumour recurrence have been observed following median sternotomy. Conclusions: Median sternotomy should be considered as an alternative approach to thoracotomy for right EPP.

Key Words: Malignant mesothelioma • Extrapleural pneumonectomy • Sternotomy


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
 References
 
The standard surgical approach for right extrapleural pneumonectomy in the setting of malignant pleural mesothelioma is via a right posterolateral thoracotomy, at one or two intercostal levels [1,2]. Anatomical pulmonary resections, particularly right upper lobectomy, have been described through median sternotomy [3], but the feasibility of performing extended surgery such as extrapleural pneumonectomy with this approach has not been explored. Right pneumonectomy for non-small cell lung cancer is related to a higher operative mortality and morbidity, particularly following neoadjuvant chemotherapy. We hypothesized that the potential benefits of performing right EPP via a median sternotomy would include less postoperative pain and morbidity. The objective of this study was to examine the short- and long-term results of each surgical approach in our first 105 patients, in a retrospective case–control study of prospectively entered data.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 Appendix A
 References
 
2.1 Preoperative assessment
All patients had a diagnosis of malignant mesothelioma made by percutaneous core, thoracoscopic or open pleural biopsy. Definitive evidence of sarcomatoid mesothelioma was a contraindication to further assessment for radical surgery but previous pleurodesis was not. All patients underwent contrast enhanced thoracic computed tomography (CT) to exclude unresectablity due to local tumour invasion, mediastinal lymphadenopathy or contralateral pleural involvement. Contrast enhanced magnetic resonance imaging [4] was used in patients where invasion into the mediastinum or across the diaphragm required further evaluation. Positron-emission tomography (PET) has not been used routinely. Resectability was defined by the absence of mediastinal organ or diffuse chest wall involvement, or invasion below the diaphragm. Contrast enhancement of previous intercostal tube or thoracoscopy sites was not, in itself, a contraindication to radical surgery, as these were widely excised. We now advocate that patients undergo video-assisted cervical mediastinoscopy, irrespective of the size of mediastinal nodes on the CT scan [5]. Those with pathological involvement of mediastinal N2 nodes were excluded from surgery. Patients were deemed medically operable according to standard guidelines for pneumonectomy [6]. Preoperative echocardiography was employed in all patients and patients excluded if the pulmonary artery systolic pressure was greater than 35 mmHg.

2.2 Operative technique
Right and left EPP via thoracotomy were performed according to the usual techniques [1,2]. For patients undergoing median sternotomy, the incision is performed in a standard fashion. The right extrapleural plane is developed from the sternal border, separating the parietal pleura from the endothoracic fascia. Blunt dissection is continued, dividing apical attachments with electrocautery. The internal thoracic vessels may be divided at their cranial origin and excised en-bloc with the main specimen together with internal thoracic lymph nodes. Insertion of an oesophageal Pillings Maloney bougie aids in the dissection of the oesophagus. The extrapleural dissection continues inferiorly until the diaphragm is reached. The pericardium is opened followed by stapled division of right pulmonary artery and right pulmonary veins intrapericardially. The lymph nodes in the subcarinal fossa are dissected and excised and the right main bronchus divided at its origin after stapling. The incision in the pericardium is extended to excise all pericardium in contact with right parietal pleura. Finally, the diaphragm is excised en-bloc, preserving a peripheral rim of muscle for future attachment of the diaphragmatic patch. The specimen is removed en-bloc from the hemithorax through the sternotomy. Systematic lymph node dissection is performed, targeting the paratracheal, paraoesophageal and peridiaphragmatic stations; the subcarinal fossa, intercostal and internal mammary artery nodes having been dissected earlier in the procedure.

In the setting of a right EPP via median sternotomy, the pericardium is reconstructed early in the operation, occasionally before excision of the diaphragm, to minimize cardiac manipulation and haemodynamic compromise. The pericardium is replaced with a loose non-absorbable mesh patch anchored to the pericardial edges with interrupted non-absorbable monofilament sutures. Excess tension in the patch is avoided, which could compromise venous drainage into the right atrium.

We replace the diaphragm with a Gore-Tex Dual Mesh patch (W.L. Gore & Associates Inc.). This is sutured to the preserved edge of the diaphragm with continuous non-absorbable monofilament suture. A sponge retractor placed through the future intercostal drain site in the anterior axillary line facilitates retraction of the liver and placement of the sutures posteriorly (Fig. 1 ). Interrupted sutures are placed posteriorly and laterally, completing with semi-continuous sutures. An intercostal muscle flap is raised via the sternotomy and secured to the bronchial stump with interrupted absorbable sutures.


Figure 1
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  		Fig. 1. Photograph showing the position of the sponge holder placed through the intercostal drain site for liver retraction.

 
At the end of the procedure (Fig. 2 ), the oesophageal bougie is replaced by a nasogastric tube that will remain on free drainage during the first 48 h. The patient is then extubated routinely in the operating theatre and transferred to the Thoracic High Dependency Unit (Fig. 3 ).


Figure 2
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  		Fig. 2. The completed operation, before wound closure, showing the diaphragmatic patch, pericardial patch and intercostals drain secured in situ.

 

Figure 3
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  		Fig. 3. Kaplan–Meier plot showing the differences in survival between the three surgical groups. Median, 1-year and 2-year survival rates were 18.3 months, 61.8% and 40.0% for the left thoracotomy group, 8.5 months, 36.4% and 13.6% for the right thoracotomy group and 17.7 months, 69.3% and 37.8% for the sternotomy group (p = 0.02, right thoracotomy vs. sternotomy).

 
2.3 Postoperative care
Patients recover in the Thoracic High Dependency Unit, where continuous monitoring of cardiac rhythm, arterial blood pressure, central venous pressure, oxygen saturation and urine output are performed. The intercostal drain is unclamped hourly to monitor blood loss and removed between 48 and 72 h postoperatively. The nasogastric tube is usually removed at 48 h, once bowel sounds have returned. Unless suffering from complications, patients are allowed to drink free fluids and mobilise within 48 h.

2.4 Statistical methods
Clinicopathological [7], surgical, oncological and follow-up data were entered prospectively into a database. Statistical analysis was performed using the SPSS software system (SPSS for Windows Version 11.0, SPSS Inc., Chicago, USA). Differences between groups were analysed with the Chi squared, Fisher's exact test and Student's t-test, where appropriate. Survival curves were estimated using the Kaplan–Meier method and the log-rank test was used to assess the statistical significance of differences between groups. A Cox proportional hazards regression model was used to identify statistically significant differences in survival and estimate hazard ratios and 95% confidence intervals (CI) [8]. The assumption of proportional hazards was assessed graphically by plotting log[–log(survivor)] against log(time) for each of the prognostic groups. Prognostic variables identified by univariate analysis were analysed in a multivariate Cox model. A forward, stepwise selection procedure was used, with variables being added to the model according to a partial likelihood ratio test, using an entry criterion of p < 0.05. Survival analyses were performed on an intention to treat basis, with the five patients who required a thoracotomy in addition to the sternotomy included in the sternotomy alone group.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 Appendix A
 References
 
3.1 Patients
One hundred and five consecutive patients from August 1999 were included in the study. Preoperative mediastinal staging by video-assisted mediastinoscopy was performed in 43 patients, including 2 patients who also underwent a positron emission tomographic scan. Positron emission tomography alone was used as mediastinal staging in a further three patients. Left EPP was performed in 50 patients, of whom 22 required a two level thoracotomy. Right EPP was performed in 55 patients, by sternotomy alone in 28, combined sternotomy and thoracotomy in 5, two-level thoracotomy in 21 and by single level thoracotomy in 1 patient.

Neoadjuvant cisplatin-based chemotherapy was administered in more patients undergoing left thoracotomy (p = 0.06) and sternotomy (p = 0.007) than right thoracotomy. There were no significant differences in the proportions of patients receiving adjuvant chemotherapy (within 3 months of surgery) between the three groups.

With the exception of EORTC prognostic score [9], there were no differences between groups in terms of the following clinicopathological prognostic factors: performance status, CALGB prognostic group [10], chest pain, weight loss, haematological indices, gender or histological cell type (data not shown). There were more patients with a high-risk EORTC score in the sternotomy group (p = 0.03).

3.2 Operative results
Of the 33 in sternotomy group, 28 were accomplished by sternotomy alone. Four of the cases requiring a thoracotomy in addition to sternotomy occurred in the first 14 of this cohort, suggesting a possible reduction in likelihood of the double incision with experience (p = 0.06). The operation time was quicker in group sternotomy and left thoracotomy than in right thoracotomy (p = 0.008 and p = 0.025). There was no difference in the rate of microscopic complete resection between the groups (p = 0.8). Complete local excision (R0) was reported in 60%. The majority of patients were UICC Stage III: there was no difference in any of the stage criteria between the three groups. Thirty day or in-hospital death occurred in one (2%), three (13.6%) and three (9.1%) in the left thoracotomy, right thoracotomy and sternotomy groups respectively.

3.3 Postoperative course
Epidural usage was compared between the two right EPP groups. The total epidural volume for the first 72 h after surgery was significantly lower in the sternotomy group (p = 0.001). There was no difference in the maximum pain score or the duration of epidural usage. We have published previously the post-operative complications in a smaller series of these patients [11]. In this study, a greater proportion of patients in the right thoracotomy group suffered complications than in the sternotomy group (17 patients in each, p = 0.05). There was no difference in cardiovascular, respiratory or infectious complications between the groups. Compared with EPP performed by sternotomy, four patients suffered wound complications in the right thoracotomy group. No patients in the sternotomy group developed wound complications (p = 0.02). Furthermore, we have not noted recurrence of tumour seedlings in the sternotomy wound, although one patient in this group developed recurrence at the site of a previous drain site in the anterior axillary line. Postoperative hospital and ICU stay were similar in the three groups (Tables 1–3 ).


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  		Table 1 Oncological therapy according to the surgical groups
 

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  		Table 2 Results of right extrapleural pneumonectomy via sternotomy and thoracotomy
 

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  		Table 3 The distribution of pathological data according to the surgical groups
 
3.4 Survival
Overall median survival for the whole cohort was 14.5 months. One- and 2-year survival rates were 59 and 31% respectively. For patients with epithelioid histology and N0 stage, these figures were 26.4 months, 78and 55%, respectively. Patients undergoing sternotomy lived for longer than those who had right EPP performed via a thoracotomy alone (p = 0.02, Table 5, Fig. 2). The other prognostic variables identified in univariate analysis by the log rank test were the histological cell type, performance status, the haemoglobin concentration at diagnosis, the presence of N2 lymph node metastases, and the receipt of neoadjuvant or adjuvant chemotherapy (Table 4 ).


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  		Table 5 Cox multivariate regression analysis
 

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  		Table 4 Prognostic significance of clinicopathological variables
 
In Cox proportionate hazards multivariate analysis, the variables identified as independent predictors of poor prognosis were haemoglobin concentration less than 14.0 g/dl at diagnosis, right EPP via thoracotomy, the presence of N2 lymph node metastases and not receiving neoadjuvant or adjuvant chemotherapy (Table 5 ). Excluding the left EPP patients from the Cox proportionate hazards multivariate model did not leave sufficient events (deaths) for meaningful analysis.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
Appendix A
 References
 
The use of medial sternotomy for bilateral wedge metastatectomy is well established [3,12]. In comparison with thoracotomy, in this setting the benefits reported are decreased postoperative pain, lesser analgesic requirements, lower incidence of respiratory complications, quicker recovery of postoperative pulmonary function and shorter hospital stay [3,13,14]. Lung volume reduction surgery is also performed effectively via a sternotomy. The indications for sternotomy were extended to anatomical lung resection, with certain authors proposing its adoption as a standard approach [13,15,16]. Anatomical resections of right lung and the left upper lobe are reported, but there is potentially more difficulty in performing resections which include the left lower lobe due to the location of the left inferior pulmonary vein and the heart. We have only encountered a single previous report describing the use of sternotomy with an additional supraclavicular incision for a case of mesothelioma with involvement of supraclavicular lymph nodes [17].

Following on from our initial report [18], we describe here our evolving experience performing routinely right EPP via a median sternotomy. In the current series of 33 patients undergoing EPP by sternotomy, we noted shorter operating times and less analgesic requirement postoperatively. We have previously reported that long operation time is an important risk factor for postoperative complications [11]. We employ routinely thoracic epidural analgesia for EPP and therefore, although the amount of epidural usage was lower in the sternotomy group, we may not have seen a substantial difference in postoperative morbidity due to the good control of pain gained with either surgical approach. However, the overall incidence of complications was lower in the sternotomy group. There are potential longer-term pain control benefits which deserve investigation, such as the potential avoidance of intercostals neuralgia. The incidence of chronic postoperative pain amongst patients following EPP is not clearly documented. It is interesting to hypothesise that sternotomy would avoid post-thoracotomy pain, but the possible contribution of parietal pleural stripping to intercostals neuralgia might remain and there is an incidence of chronic post-sternotomy pain [19].

Wound complications are relatively rare following median sternotomy and we did not experience any wound complications in this series. Neither have we yet seen tumour implantation in the sternotomy wound, although this phenomenon is well described after other incisions and needle tracks for mesothelioma. We hypothesise that this is due to the median sternotomy skin incision is distant to the pleural reflection. We are not aware of any patients suffering from sternal bone ‘metastases.’

We did not observe a difference in hospital stay between the right sternotomy and thoracotomy groups. This may be due to the policy that we have adopted, midway through the series, to transfer patients back to the referring hospital, rather than to allow discharge directly home. Patients may therefore be staying longer in our unit later.

There appears to have been a learning curve in patient selection for this technique. The first patient undergoing sternotomy had tumour related to the superior vena cava and we felt that it would be easier to gain access by sternotomy. We found that we were able to complete the EPP via sternotomy alone. An additional thoracotomy has been required five times and this is becoming less frequent with greater experience. The technical developments contributing to this include the use of the intercostal drain hole to place a liver retractor during dissection around the inferior vena cava and secondly rib resection (where required) via the sternotomy, rather than a separate thoracotomy. The retractor placed through the lateral drain hole also assists in placing the interrupted sutures for the diaphragmatic patch.

The survival data suggest that patients undergoing right EPP via a thoracotomy do not experience the same longevity as those who had a sternotomy. This effect may be related to the quicker and less morbid postoperative recovery experienced following sternotomy leading to a shorter period of relative immunosuppression. However, this cohort of our first 105 patients represents the evolution of a number of aspects of our practice which may also affect survival. These include the introduction of adjuvant and neoadjuvant chemotherapy, neither of which have yet to be adopted routinely by all our 28 referring oncological centres, but which is now a consistent predictor of good prognosis in multivariate analysis. Our preoperative assessment initially included routine contrast-enhanced magnetic resonance imaging, the use of which has waned with the introduction of multislice spiral CT. All patients now have preoperative pathological staging of the mediastinum by video-assisted cervical mediastinoscopy, regardless of whether the targeted nodes are less than 1 cm in short axis diameter. These changes in methodology account for limitations in the conclusions we may draw from survival data in univariate and multivariate analyses. Furthermore, the two right EPP groups are sequential cohorts of patients. A prospective randomised controlled trial would be required to examine the potential survival benefits of performing right EPP via a median sternotomy.

In conclusion, right EPP via median sternotomy is a feasible alternative to the standard one or two-level posterolateral thoracotomy. It is quicker, requires less post-operative epidural anaesthesia and is associated with fewer postoperative complications. The oncological result is unchanged in terms of the completeness of resection and adequacy of nodal staging and there may be a survival benefit over thoracotomy.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
References
 
Conference discussion

Dr M. Dusmet (London, United Kingdom): I do have one question, one issue I would like you to address. I am struck in the abstract by the way the survival between right thoracotomy and left thoracotomy is so completely different, with a median survival of 259 and 658 days, respectively. Now, obviously the right thoracotomy patients were earlier in your experience because we know that over the last 5, 6 years you have converted to the sternotomy, but, to my mind, until you have explained in a satisfactory manner the 259-day median survival for right thoracotomy as opposed to more than double for left thoracotomy, I have a hard time accepting that sternotomy per se improves survival because this seems to be an anomalous number. I would appreciate your comments on that.

Dr Edwards: I accept that this is not a prospective randomized study. What I would draw your attention to is the multivariate analysis that I showed towards the end of the presentation. This showed that the right sternotomy approach was an independent poor prognostic factor in addition to chemotherapy. The use of chemotherapy in our series has increased throughout the course of time, but, as I say, there is a difference that is independent of chemotherapy with the right sternotomy group. It is difficult to know exactly why without a prospective study, and, of course, that is something that perhaps should be done in the future.

Dr Dusmet: I’m still not convinced, because multivariate analysis is done on the basis of the raw data, and the raw data still has what appears to me to be an unexplained anomaly. So until you explain that apparent anomaly in a satisfactory manner, I cannot accept the conclusions of your multivariate analysis.

Dr Edwards: I take your point, and it would take a prospective randomized trial with equal oncological treatments in both groups to show that the survival benefit is due to the surgical approach. However, as you can see on the screen, there are other benefits to the approach in terms of the fact that it's quicker, it's less painful, it's less morbid, and it has fewer complications. I think those are just as important as the survival benefit.

Dr M. Zielinski (Zakopane, Poland): Maybe I am too pessimistic about the results of treatment of mesothelioma, but in my opinion, in my experience, it is a totally incurable disease now, and everything we can do is to prolong the life to some extent, nothing more. The main cause of death in the experience of my team is the recurrence in the abdomen.

I would like to ask you a question. You showed the results that the sternotomy approach prolonged the survival. What were the causes of death in your material? I think regardless if you perform sternotomy or thoracotomy, the patient dies from the intra-abdominal recurrence. The approach has no role in that. So what were the causes of death in your patients?

Dr Edwards: I will refer you to the paper that we have published showing our patterns of recurrence following extrapleural pneumonectomy in our series, but we have seen recurrence both locally and distally and in the abdomen, and I think it's about one-third of patients have recurrence in the abdomen at the time of death. But, as I say, what is important, what is interesting with this series is that we didn’t see any wound recurrence in the sternotomy wound, which I think is interesting.

Dr Zielinski: In other words, how can you explain in what way sternotomy prolongs survival? That's the point.

Dr Edwards: What I’m saying is that there is an association with increased survival. I’m not suggesting that this is a causal relationship.

Dr Waller: I would just like to address the chairman's apparent misunderstanding of why he cannot understand the difference between left and right. Let me draw you to two pieces of well-published evidence. One is the higher mortality associated with right pneumonectomy compared to left pneumonectomy for non-small cell lung cancer for well-known reasons, such as cardiovascular mortality, which would largely explain some of the differences in the mortality between left EPP and right EPP, and also the presentation we made at this society, I think it was in 2005, which has been published in the European Journal of Cardiothoracic Surgery which highlighted the prognostic indicators for survival in our series, which included length of operation, and I will put it to you that the reason there is a difference between right thoracotomy and median sternotomy is the reduction in the operating time, which we know is associated with postoperative complications. The difference between the left and the right relates to the anatomy and removing a right lung compared to a left lung.

Dr Dusmet: If the differences were exclusively the difference between right and left thoracotomy, I would have expected to see a degree of that remaining after sternotomy.

Dr F. Leo (Milan, Italy): Again, regarding survival and median sternotomy, don’t you think that there is a major bias in selection of patients mainly due to the extent of the disease?

Dr Edwards: As I showed, the T stage and the N stage and the overall stage were the same between the groups. These are sequential cohorts and we have not changed our selection criteria throughout the course of the series.

Dr Leo: Sure, but if you have bulky disease on the diaphragm, I’m not sure that you can be radical with median sternotomy.

Dr Edwards: It makes the operation difficult, but it is still feasible.

Dr D. Branscheid (Grosshansdorf, Germany): First, what type of histology did you find? Did you treat sarcomatous, epithelial, or biphasic ones? Second, what was the stage? How extended were those tumors?

Dr Edwards: Firstly, histology, we did not include patients who had definite nonepithelioid tumors in this group; however, some patients following radical surgery were found to have biphasic rather than pure epithelioid tumors. Secondly, the vast majority of our patients, as in other international series, are stage III patients.


   Footnotes
 
\#9734; Presented at the joint 20th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 14th Annual Meeting of the European Society of Thoracic Surgeons, Stockholm, Sweden, September 10–13, 2006.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
 References
 

  1. Sugarbaker DJ, Heher EC, Lee TH, Couper G, Mentzer S, Corson JM, Collins Jr. JJ, Shemin R, Pugatch R, Weissman L. Extrapleural pneumonectomy, chemotherapy, and radiotherapy in the treatment of diffuse malignant pleural mesothelioma. J Thorac Cardiovasc Surg 1991;102:10-15.[Abstract]
  2. Rusch VW, Piantadosi S, Holmes EC. The role of extrapleural pneumonectomy in malignant pleural mesothelioma. J Thorac Cardiovasc Surg 1991;102:1-9.[Abstract]
  3. Cooper JD, Nelems JM, Pearson FG. Extended indications for median sternotomy in patients requiring pulmonary resection. Ann Thorac Surg 1978;26:413-420.[Abstract]
  4. Stewart D, Waller DA, Edwards JG, Jeyapalan K, Entwisle 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]
  5. Pilling JE, Stewart DJ, Martin-Ucar AE, Muller S, O’Byrne KJ, Waller DA. The case for routine cervical Mediastinoscopy prior to radical surgery for malignant pleural mesothelioma. Eur J Cardiothorac Surg 2004;25:497-501.[Abstract/Free Full Text]
  6. British Thoracic Society. Guidelines on the selection of patients with lung cancer for surgery. Thorax 2001;56:89-108.[Free Full Text]
  7. Edwards JG, Abrams KR, Leverment JN, Spyt TJ, Waller DA, O’Byrne KJ. Prognostic factors for malignant mesothelioma in 142 patients: validation of CALGB and EORTC prognostic scoring systems. Thorax 2000;55:731-735.[Abstract/Free Full Text]
  8. Cox D. Regression models and life tables. J Royal Stat Soc 1972;34:187-220.
  9. Curran D, Sahmoud T, Therasse P, Van Meerbeeck J, Postmus PE, Giaccone G. Prognostic factors in patients with pleural mesothelioma: the european organisation for research and treatment of cancer experience. J Clin Oncol 1998;16:145-152.[Abstract/Free Full Text]
  10. Herndon JE, Green MR, Chahinian AP, Corson JM, Suzuki Y, Vogelzang NJ. Factors predictive of survival among 337 patients with mesothelioma treated between 1984 and 1994 by the cancer and leukemia group B. Chest 1998;113:723-731.[Abstract/Free Full Text]
  11. Stewart DJ, Martin-Ucar AE, Edwards JG, West K, Waller DA. Extra-pleural pneumonectomy for malignant pleural mesothelioma: the risks of induction chemotherapy, right-sided procedures and prolonged operations. Eur J Cardiothorac Surg 2005;27(3):373-378.[Abstract/Free Full Text]
  12. Roth JA, Pass HI, Wesley MN, White D, Putnam JB, Seipp C. Comparison of median sternotomy and thoracotomy for resection of pulmonary metastases in patients with adult soft-tissue sarcomas. Ann Thorac Surg 1986;42(2):134-138.[Abstract]
  13. Urschel Jr. HC, Razzuk MA. Median sternotomy as a standard approach for pulmonary resection. Ann Thorac Surg 1986;41:130-134.[Abstract]
  14. Asaph JW, Handy Jr. JR, Grunkermeier GL, Douville EC, Tsen AC, Rogers RC, Keppel JF. Median sternotomy versus thoracotomy to resect primary lung cancer: analysis of 815 cases. Ann Thorac Surg 2000;70:373-379.[Abstract/Free Full Text]
  15. Asaph JW, Keppel JF. Midline sternotomy for the treatment of primary pulmonary neoplasms. Am J Surg 1984;147(5):589-592.[CrossRef][Medline]
  16. Watanabe Y, Ichihashi T, Iwa T. Median sternotomy as an approach for pulmonary surgery. Thorac Cardiovasc Surg 1988;36(4):227-231.[Medline]
  17. Murata S, Kohiyama R, Tanaka M, Miyamoto H, Hata E. Extended extrapleural pneumonectomy by median approach for advanced malignant mesothelioma with right supraclavicular lymph node metastasis—a case report. Nippon Kyobu Geka Gakkai Zasshi 1994;42:404-408.[Medline]
  18. Martin-Ucar AE, Stewart DJ, West KJ, Waller DA. A median sternotomy approach to right extrapleural pneumonectomy for mesothelioma. Ann Thorac Surg 2005;80(3):1143-1145.[Abstract/Free Full Text]
  19. Kalso E, Mennander S, Tasmuth T, Nilsson E. Chronic post-sternotomy pain. Acta Anaesthesiol Scand 2001;45(8):935-939.[CrossRef][Medline]



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John G. Edwards
Antonio E. Martin-Ucar
Duncan J. Stewart
David A. Waller
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