Trimodality therapy (TMT; extrapleural pneumonectomy (EPP), chemotherapy and radiation therapy) offers the potential of optimal survival in selected patients with Brigham stage I–II epitheliod mesothelioma based on CT, MRI and PET scanning. We hypothesized that these scanning modalities were inadequate to accurately stage these patients.Methods: Patients suitable for TMT, in addition to CT, MRI and PET scanning, prior to EPP, underwent bilateral thoracoscopy, mediastinoscopy and laparoscopy (surgical staging). Follow-up CT scans were performed, six monthly, quality of life assessments yearly.Results: From 1 June 2004 to 28 February 2007, 34 patients were referred; mean age was 66 years (range: 44–69). Surgical staging was performed in 30 patients; 24 patients were confirmed as Brigham Stage I–II. However, six were upstaged, five as stage IV disease (one contralateral chest, two contralateral chest and abdomen, two abdomen) and one as mediastinal node positive; two further patients were reclassified histologically (one sarcomatoid, one biphasic). These eight patients fared poorly, 50% dying within 1 year from mesothelioma. Following surgical staging, 3 patients declined further surgery; thus, 19 patients proceeded to surgery, 3 were unresectable and 16 received EPP. Follow-up of all 34 patients is complete.Conclusion: Surgical staging identified 26% of patients who would have received no benefit from TMT.