MEDIASTINOSCOPY

Mediastinoscopy in the investigation of primary mediastinal lymphadenopathy

Mediastinoscopy was introduced by Carlens (1) in 1959 to obtain lymph node biopsies from the superior mediastinum in patients with bronchogenic carcinoma. The technique has been widely accepted for clinical staging as a guide to operability and prognosis. We report on a consecutive retrospective series of 110 patients undergoing mediastinoscopy between 1982-1986 for primary mediastinal lymphadenopathy in order to assess the diagnostic value and safety of the procedure. Mediastinoscopy gave a positive histological diagnosis in 74.5% of cases with no false negative results. There were no deaths and one complication only (pneumothorax). This study shows mediastinoscopy to be a safe, accurate and cost effective procedure minimising hospital stay and allowing appropriate treatment to be immediately commenced upon diagnosis. Mediastinoscopy obviates the need for expensive computed tomography or nuclear magnetic resonance scans and we conclude that it is the investigation of choice for primary mediastinal lymphadenopathy after confirmation by plain chest radiography.

Pre-operative mediastinal evaluation in primary bronchial carcinoma--a review of staging investigations

A review of staging investigations in the preoperative evaluation of mediastinal involvement in primary bronchial carcinoma is presented. The following conclusions are offered as guidelines for the use of mediastinal staging procedures in clinical practice: Surgical staging methods have the over-riding advantage of superior specificity over indirect imaging techniques. Where 67Ga-imaging or CT scanning are not available, routine pre-operative mediastinoscopy or, when appropriate, mediastinotomy will identify most patients with non-resectable disease but this approach entails a high proportion of true negative examinations. Radioisotope ventilation and perfusion lung imaging has no place in the pre-operative staging of lung cancer. Where the techniques are available, 67Ga-imaging and CT scanning have a use in selecting patients for mediastinal exploration. A negative mediastinal 67Ga scan or a negative CT examination suggest that mediastinal exploration will be unrewarding in the vast majority of cases and may be omitted prior to thoracotomy. A positive mediastinal 67Ga scan or the demonstration of abnormal mediastinal nodes by CT is an indication for mediastinal exploration which, if negative should be followed by thoracotomy.

Selection by mediastinoscopy and long-term survival in bronchial carcinoma

In order to reduce the high rate of inoperability in patients with bronchial carcinoma, mediastinoscopy was carried out as a routine preoperative selection in 874 patients during 13 years. Two hundred thirty-six patients (27%) were found to have involved lymph nodes at mediastinoscopy and were not treated surgically. Follow-up data were available on 210 of them: 165 (79%) died within a year, 16 survived for 2 years, and 4 for 5 years. Pulmonary resection was carried out in 638 patients. Five-year survival in the series was 24.5% and 10-year survival (based on 104 eligible patients), 16.3%, including the operative mortality of 5.5%. Mediastinoscopy has not improved long-term survival to any great extent. However, it has raised the rate of resectability to 97.1% and lowered the operative mortality without denying the patient a chance of cure.

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.

The early diagnosis of lung cancer

Earlier diagnosis of malignant disease in the lung may bring about improvements in the treatment. This article discusses the effects of early diagnosis on the prognosis. Cancer of the lung may be associated with other lung pathology, thus increasing the problems of diagnosis. Diagnosis depends on radiological examination, cytology of the sputum, radio-isotope lung scanning and mediastinoscopy: an account is given of how these may be used to diagnose the condition whilst it is still at an early stage and suitable for radical treatment.

Mediastinoscopy: a diagnostic procedure in hilar and paratracheal lymphadenopathy

Mediastinoscopy, in the skilled hands of a thoracic surgeon, is a safe, cosmetically accepted procedure with negligible complications, less than that reported in many series of scalene node biopsies.

It has the advantage of yielding a much higher rate of diagnostic tissue, in all instances over 90%. In the cases of tuberculosis it enabled an organism to be isolated and sensitivities obtained.

It has also revealed a group of cases with findings, a further study of which may increase our understanding, assessment and management of patients presenting with hilar and/or paratracheal lymphadenopathy.

Mediastinoscopy

The surgical and anaesthetic technique used in mediastinoscopy during the investigation of 124 patients is described. A histological diagnosis was made in 109 cases (88%). Of the 22 cases other than sarcoidosis a positive diagnosis was obtained in all. In 102 cases with suspected sarcoidosis, the histological appearances of the nodes were compatible with sarcoid in 86 (84%). No serious complications were encountered. It is concluded that this procedure should be carried out by an experienced thoracic surgeon and will yield better diagnostic tissue than other comparable procedures.

Pericardial cyst in the superior mediastinum treated by mediastinoscopy. A case report

A case of pericardial cyst in the superior mediastinum has been described. This is only the ninth such patient to be reported in the literature and the first one in which diagnosis and treatment have been carried out by mediastinoscopy.

Mediastinoscopy: a clinical evaluation of 400 consecutive cases

Mediastinoscopy was carried out in 400 cases, including 296 of bronchogenic carcinoma. At the time of presentation the new growth had already spread to involve the mediastinal lymph nodes in slightly more than 50% of these. The incidence of involvement was 76% in oat-cell and 35% in squamous-cell carcinoma. Non-resectability at thoracotomy was encountered in seven out of 120 patients. We advocate this procedure in every case of bronchogenic carcinoma which is considered operable on other counts. In patients in whom the mediastinal lymph nodes are invaded by growth we prefer radical radiotherapy to surgery, as the long-term survival of the two methods is comparable. This procedure may be the only source of positive histological proof of diagnosis, not only in carcinoma but in other types of intrathoracic disease. We believe that this procedure reduces the number of unnecessary exploratory thoracotomies.