Mediastinal exploration by mediastinoscopy and mediastinotomy

The role of mediastinoscopy in the diagnosis of non-lung cancer diseases

BACKGROUND

Mediastinoscopy is a good method to evaluate mediastinal lesions. We sought to determine the current role of mediastinoscopy in the investigation of non-lung cancer patients with mediastinal lymphadenopathy.

MATERIALS AND METHODS

We retrospectively reviewed clinical parameters (age, gender, histological diagnosis, morbidity, mortality) of all patients without lung cancer who consecutively underwent mediastinoscopy in Hospital of Faculty of Medicine of Dicle University between June 2003 and December 2016.

RESULTS

Two-hundred twenty nine patients without lung cancer who underwent mediastinoscopy for the pathological evaluation of mediastinum during the study period were included. There were 156 female (68%) and 73 male (32%) patients. Mean age was 52.6 years (range, 16 to 85 years). Mean operative time was 41 minutes (range, 25 to 90 minutes). Mean number of biopsies was 9.3 (range, 5 to 24). Totally, 45 patients (19.6%) had previously undergone a nondiagnostic bronchoscopic biopsy such as transbronchial needle aspiration or endobronchial ultrasound-guided transbronchial needle aspiration. Mediastinoscopy was diagnostic for all patients. Diagnosis included sarcoidosis (n=100), tuberculous lymphadenitis (n=66), anthracosis lymphadenitis (n=44), lymphoma (n=11) metastatic carcinoma (n=5), and Castleman's disease (n=1); there was a diagnosis of silicosis in one patient and tymoma in one patient. Neither operative mortality nor major complication developed. The only minor complication was wound infection which was detected in three patients.

CONCLUSION

Although newer diagnostic modalities are being increasingly used to diagnose mediastinal diseases, mediastinoscopy continues to be a reliable method for the investigation of mediastinal lesions.

Combined Video-Assisted Mediastinoscopy and Thoracoscopy in the Management of Lung Cancer: A Five-Year Experience

OBJECTIVE

The aim of this study was to assess the usefulness of combined video-assisted mediastinoscopy (VM) and video-assisted thoracoscopy (VT) in the management of patients with lung cancer.

METHODS

A prospective observational study was performed over a 5-year period. Indications for combined VM and VT included inconclusive findings from imaging techniques concerning locoregional extension and resectability; possible involvement of different structures not accessible to a single procedure; and failure to obtain a histologic diagnosis with a single technique.

RESULTS

An indication for combined exploration was established in 30 patients, representing 2.6% of all the patients referred to us for diagnosis, staging, and/or resection of lung cancer. Combined VM and VT was completed in 28 patients, as pleural carcinosis was found at VT in 2 cases. There was no mortality or morbidity in our series. Histologic diagnosis was obtained in 12/13 patients without preoperative histologic typing. In all the evaluated patients, combined VM and VT was useful in clinical decision-making, leading to immediate surgery (n=10), induction treatments (n=8), or nonsurgical therapy (n=12). Among the patients who underwent immediate surgery, combined VM and VT never failed to assess the T factor. The N factor was correctly evaluated in 8/10 patients, and in 2 patients it failed to recognize a minimal N2 disease.

CONCLUSION

Combined VM and VT is a safe and useful tool in the management of selected patients with lung neoplasms. Both the extent of primary tumor and the possible intrathoracic spread can be thoroughly evaluated.

Mediastinoscopy and mediastinotomy after cardiac surgery: are safety and efficacy affected by prior sternotomy?

BACKGROUND

The diagnostic and staging value of cervical mediastinoscopy is well established. Left anterior mediastinotomy is of further value in assessing left upper lobe tumors. However the efficacy and safety of both these procedures after median sternotomy for cardiac surgery is unknown.

METHODS

We undertook a retrospective review of our experience of mediastinal exploration by cervical mediastinoscopy with or without left anterior mediastinotomy in patients with prior sternotomy between 1980 and 2001.

RESULTS

During this period 28 patients (25 male and 3 female; mean age, 63 +/- 10 years), all with prior sternotomy for cardiac surgery (14 had left internal mammary artery graft), underwent mediastinal exploration. The mean interval between sternotomy and mediastinal exploration was 7.2 +/- 5.1 years. Additionally, 3 patients also had superior vena cava obstruction. Cervical mediastinoscopy was performed in all 28 patients and additionally left anterior mediastinotomy was undertaken in 7 of 28 patients (4 with left internal mammary artery graft). Indications for exploration were staging of lung cancer in 22 patients (cervical mediastinoscopy, n = 22; left anterior mediastinotomy, n = 7) and diagnostic biopsy of mediastinal mass in 6 patients (cervical mediastinoscopy, n = 6). Thorough mediastinal assessment was possible in all 28 patients. In the 22 patients with lung cancer the median number of lymph node stations sampled during mediastinoscopy was 3 (range, 1 to 5). A specific diagnosis was obtained in 16 patients (metastatic lung cancer, n = 10; lymphoma, n = 3; sarcoidosis, sinus histiocytosis, and metastatic melanoma, n = 1 each). The other 12 patients with negative findings underwent pulmonary resection and only 1 of 12 (8%) patients had unexpected N2 disease, a similar proportion to our overall experience with lung cancer. There were no operative complications.

CONCLUSIONS

Prior sternotomy for cardiac surgery does not compromise the efficacy and the safety of mediastinoscopy and mediastinotomy.

Bronchoscopy and surgical staging procedures and their correlation with imaging

Bronchoscopy, computed tomography (CT) and surgical staging procedures are complimentary methods of investigating patients with lung cancer. CT has been shown to be of value prior to bronchoscopy in the investigation of haemoptysis and malignancy, with excellent correlation between the detection of disease within the large airways on CT and direct visualisation at bronchoscopy. The utility of CT has been further increased by the development of multislice scanners with the generation of volumetric data enabling multiplanar image acquisition. Additionally the advent of CT co-registered with positron emission tomography will play an important role in guiding the choice of surgical staging procedures The increasing use of multidisciplinary medical care requires radiologists to have a greater understanding of the abilities and limitations of both bronchoscopy and surgical staging procedures in evaluating disease demonstrated on imaging.

Video-assisted thoracoscopic surgery for diagnosis, staging, and management of lung cancer with suspected mediastinal lymphadenopathy

The aim of this report was to evaluate the effectiveness of video-assisted thoracoscopic surgery (VATS) in staging, diagnosis, and treatment of lung cancer. Fifty-two patients were scheduled for mediastinal lymph node VATS biopsy at the Oncologic Thoracic Surgery Department of the National Cancer Institute in Milan. Fifty patients underwent lymph nodal thoracoscopic biopsy (96%), whereas for the other 2 patients, histologic diagnosis was done by pleural metastatic nodule thoracoscopic biopsy (4%). We performed 17 lymph nodal biopsies in level 5 (33%), 14 in level 6 (27%), 12 in level 7 (23%), and 7 in level 8 (13%). No postoperative complications were observed, and 19 subjects (36%) underwent open lung resection. The histologic diagnosis was adenocarcinoma in 25 cases (48%), epidermoid carcinoma in 14 (27%), microcytoma in 9 (17%), and giant-cell lung carcinoma in 4 (8%); 10 patients were at stage I (19%), 9 at stage II (17%), 31 at stage III (60%), and 2 at stage IV (4%). The use of VATS allowed diagnosis of the suspected involved mediastinal lymph nodes in lung cancer patients and obviated the need for painful thoracotomy, enabling accurate staging and thus selection of the optimal treatment.

Combined video-assisted mediastinoscopy and video-assisted thoracoscopy in the management of lung cancer

BACKGROUND

This study seeks to assess the safety and usefulness of combined video-assisted mediastinoscopy and video-assisted thoracoscopy in the management of patients with lung cancer.

METHODS

Ten consecutive patients with lung neoplasms were evaluated. Indications for this combined approach included inconclusive findings from imaging techniques concerning locoregional extension and resectability; possible involvement of different structures not accessible to a single procedure; and failure to obtain histologic diagnosis by a single technique. RESULTS; Histologic diagnosis was obtained in 6 patients without preoperative histologic typing. In 3 patients, in contrast with preoperative imaging studies, combined thoracoscopy and mediastinoscopy showed the resectability of the primary tumor and the absence of metastatic mediastinal lymph nodes. These findings were confirmed at thoracotomy. In 3 other patients prevascular lymph nodes metastases were found. They underwent neoadjuvant chemotherapy; at subsequent operation, a complete resection was possible. In the remaining four cases combined exploration proved definitive contraindications for operation (recognition of oat-cell carcinoma, n = 2; T4 status, n = 1; T3N2, n = 1).

CONCLUSIONS

Combined video-assisted mediastinoscopy and video-assisted thoracoscopy seems to be a safe and useful tool in the management of selected patients with lung neoplasms. Both the extent of primary tumor and the possible intrathoracic spread may be exhaustively evaluated. In patients with left lung cancer a complete exploration of the aortopulmonary window is possible.

The role of mediastinoscopy in superior vena caval obstruction

The role of mediastinoscopy in superior vena caval obstruction is not defined. To examine the safety and efficacy of mediastinoscopy, we reviewed 34 patients with superior vena caval obstruction who required mediastinoscopy to establish a histologic diagnosis after less invasive techniques had failed. They were referred to one surgical team between 1982 and 1993. Of the 34 patients, 26 had lung cancer, 6 had lymphoma, 1 had malignant thymoma, and 1 had fibrosing mediastinitis. Definitive tissue diagnosis was obtained in all patients. There was one complication of mediastinoscopy where arterial bleeding from the innominate artery occurred and limited sternotomy was required to control the bleeding. We conclude that mediastinoscopy is a safe and effective technique for establishing histologic diagnosis in superior vena caval obstruction when less invasive techniques have been unsuccessful. The use of blind radiotherapy means that patients with lymphoma and small cell carcinoma will not receive optimum therapy with chemotherapy and patients with benign lesions will receive inappropriate therapy.

Mediastinoscopy as a routine outpatient procedure

We reviewed our experience performing mediastinoscopy as an outpatient procedure. From January 1, 1987, to December 31, 1992, 1,015 of 1,062 cervical mediastinoscopies were performed on an outpatient basis. There were no operative deaths. Complications developed in 14 patients, 10 of whom required hospitalization. Two additional patients were hospitalized for social reasons. Supraventricular arrhythmia was the most frequent complication requiring admission to the hospital. This article documents the ability to perform mediastinoscopy safely as an outpatient procedure and discusses why this is our preferred approach in managing patients with lung cancer.

Computerised tomography does not predict N2 disease in patients with lung cancer

BACKGROUND

Mediastinal node involvement in primary lung cancer determines the staging and prognosis of the patient, and as these nodes can be seen on the computerised tomography (CT) scan of the chest it is a temptation to diagnose malignant involvement if the nodes appear enlarged. However, initial experience with mediastinal node mapping at lung resection demonstrated this extrapolation to be unreliable and misinterpretation of enlarged nodes on CT may lead to misdiagnosis and prejudice the patient's management.

AIM

To demonstrate that the sensitivity, specificity, and accuracy of the CT to detect malignant mediastinal nodes is too low to use size of node on CT as representative of malignant involvement.

METHODS

One hundred and fifty-three sequential patients with resectable lung cancer were studied with preoperative CT. Two radiologists determined the preoperative T and N status from these studies with nodes of 1.5 cm or larger diagnosed abnormal. These results were compared to the results of subsequent node mapping performed after lung resection.

RESULTS

Sensitivity was found to be 26%, specificity to be 81% and overall accuracy 69%--too low to justify the diagnosis of N2 disease on size of 1.5 cm or larger. CT is not a valid means of diagnosing malignant involvement of mediastinal nodes.

Role of mediastinoscopy in superior vena cava obstruction

BACKGROUND

The role of mediastinoscopy in superior vena cava obstruction (SVCO) is not clearly defined. The authors set out to examine the efficacy and safety of mediastinoscopy in SVCO.

METHODS

They reviewed 14 patients referred to one surgical team over an 8-year period (1982-1990) who required mediastinoscopy to establish a histologic diagnosis after other less invasive procedures had not established the diagnosis.

RESULTS

Of the 14 patients, 11 had lung cancer, 2 had lymphoma, and 1 had malignant thymoma. Definitive tissue diagnosis was obtained in 13 cases. Mediastinoscopy was unsuccessful in one of the cases because no pathologic tissue could be identified at the time of the procedure. Tissue diagnosis could only be obtained in this patient after mediastinotomy, and a lymphoma was found. There was one complication of mediastinoscopy; one patient had arterial bleeding from the innominate artery that required limited sternotomy to control the bleeding.

CONCLUSIONS

The authors believe that mediastinoscopy is a safe and effective technique for establishing a histologic diagnosis in SVCO when less invasive techniques have been unsuccessful. The use of blind radiation therapy cannot be justified on an emergency basis; failure to obtain a histologic diagnosis will result in up to 20% of patients receiving inappropriate radiation therapy, making subsequent tissue diagnosis very difficult.

Pathological assessment of mediastinal lymph nodes in lung cancer: implications for non-invasive mediastinal staging

BACKGROUND

The use of computed tomography in mediastinal staging of lung cancer relies on the premiss that malignant lymph nodes are larger than benign ones. This hypothesis was tested by linking node size and presence or absence of malignancy and looking at factors possibly influencing the size of benign nodes.

METHODS

All accessible mediastinal lymph nodes were taken from 56 consecutive patients with lung cancer who underwent thoracotomy. Nodes were measured and histologically examined. Resected cancer bearing lung from 44 of these patients was assessed for degree of acute and chronic inflammation.

RESULTS

Lymph node size was not significantly related to the presence of metastatic disease, 58% of malignant and 43% of benign lymph nodes measuring over 15 mm. Similarly, there was no statistically significant relation between size of lymph nodes and the likelihood of malignancy, 20% of lymph nodes of 10 mm or more but also 15% of those less than 10 mm being malignant. Thresholds of 15 and 20 mm showed similar results. The maximum size of benign lymph nodes was significantly greater in those patients with histological evidence of acute pulmonary inflammation than in those without.

CONCLUSIONS

The study shows that in patients with lung cancer (1) malignant mediastinal lymph nodes are not larger than benign nodes; (2) small mediastinal lymph nodes are not infrequently malignant; and (3) benign adenopathy is more common in patients with acute pulmonary inflammation.

A comparison of cobalt (57Co) bleomycin scanning and contrast-enhanced CT scanning for assessment of the mediastinum in lung cancer

Sixty patients with histologically proven lung cancer who had been accepted for mediastinoscopy or thoracotomy were prospectively entered into a study to evaluate computed tomographic (CT) scanning, 57Co-bleomycin scanning, and barium swallow in preoperative assessment of mediastinal lymph node metastasis. Fifty-six patients had thoracotomy at which all accessible lymph nodes were sampled. Twenty-four patients were found to have mediastinal tumor on histologic analysis of the resected mediastinal lymph nodes. Neither 57Co-bleomycin scanning nor barium swallow were clinically useful, with sensitivities of 21 percent and 11 percent respectively, whereas CT scanning was helpful. However, there was no clear cutoff point of node size to optimize sensitivity and specificity for CT scanning. When nodes greater than or equal to 15 mm were taken to indicate likely malignancy, the sensitivity was 58 percent and the specificity was 87 percent and when greater than or equal to 10 mm was used the sensitivity was 80 percent but the specificity was only 55 percent. There was no clear relationship between the size of the largest resected lymph node in each patient and the presence of malignant lymph nodes. Only 42 percent of patients with resected nodes greater than or equal to 2 cm had histologic evidence of metastases. We conclude that CT scanning should be used to indicate the presence and site of mediastinal lymph nodes, which, when visualized, should always be sampled and histologically examined prior to resection of primary tumor.