Mediastinoscopy in the diagnosis of nonmalignant thoracic disease

Mediastinoscopy in relation to clinical evaluation

The aim of the study was to evaluate the entire spectrum of mediastinoscopy, from common to rare conditions, in relation to clinical judgement. The 2021 consecutive patients comprised 992 with 'open' clinical diagnoses at mediastinoscopy and 1,029 with verified or presumptive diagnoses. In the first group the most common indications for mediastinoscopy were pulmonary infiltrate (73%) and mediastinal shadow (17%), and in the second group they were bronchogenic carcinoma (57%) and sarcoidosis (38%). Mediastinoscopy was classified as positive in 43% of the first, and 60% of the second group. Of the total series, 51% had positive mediastinoscopy findings, the most common being malignant disease (24%) and sarcoidosis (21%). Mediastinoscopy was useful especially for evaluating malignant mediastinal involvement, but also for differentiation of lymphadenopathies and in diagnosis of rare diseases.

Complications of mediastinoscopy

From 1968 to 1987, mediastinoscopy was performed on 2021 consecutive patients. The procedure was carried out in 35.7 per cent on patients with a pulmonary infiltrate and in 28.8 per cent with bronchogenic carcinoma. Mediastinoscopy was positive in 54 per cent of the cases. The total number of complications was 2.3 per cent (47/2021). There were four cases with major haemorrhage, three tracheal ruptures and three wound infections. Recurrent nerve paralysis was verified in three patients and pericardial rupture in two patients. The total of major complications was 0.5 per cent (10/2021). There was no deaths in this series. In the authors' opinion, mediastinoscopy can be regarded as an effective and safe procedure in the hands of an experienced surgeon.

Thoracic lymphadenopathy in Asians resident in the United Kingdom: role of mediastinoscopy in initial diagnosis

Although the incidence of superficial glandular tuberculosis is high in Asian immigrants, a clinical diagnosis without biopsy has previously been shown to be inaccurate in 22% of cases. The role of diagnostic mediastinoscopy and biopsy in thoracic lymphadenopathy was therefore evaluated in 41 consecutive Asian patients. Tuberculosis was diagnosed by histological examination or culture (or both) of gland biopsy material in 24 (59%). A further 12 patients, however, also received antituberculous chemotherapy, with a response in 10 cases. If these are included, 34 (83%) were finally considered to have tuberculosis. The symptoms and ages of the patients with tuberculosis were similar to those typically seen in caucasians with sarcoidosis. Six had tuberculous bilateral hilar lymphadenopathy. In only four cases (10%) was a positive diagnosis other than tuberculosis established; in two (lymphoma and thymoma) mediastinoscopy confirmed preoperative suspicions, and saved only two more (with sarcoidosis and vascular anomaly) from unnecessary antituberculous treatment. Complications included severe haemorrhage (1) and chronic tuberculous sinus in the endoscopy tract (2). Mediastinoscopy is unlikely to change management in most patients, produces an appreciable amount of morbidity, and should be reserved for cases in which there is additional clinical doubt. Any future decline in the prevalence of tuberculosis in Asians may, however, require its further evaluation.

Mediastinoscopy in the diagnosis of thoracic disease

One hundred and forty-one patients have undergone mediastinoscopy in the Hong Kong University Surgical Unit since March 1974. Among these there were 109 cases of bronchogenic carcinoma. In approximately 50% of these patients the carcinoma had already spreed to involve the mediastinal lymph nodes at the time of examination. Mediastinoscopy may be the only source of positive histological proof of the diagnosis in bronchogenic carcinoma as well as in other types of intrathoracic disease such as tuberculosis. We believe that mediastinoscopy reduces the number of unnecessary exploratory thoracotomies.