Mediastinoscopy vs thoracoscopy for mediastinal biopsy. Results of a prospective nonrandomized study

Efficacy of contrast-enhanced ultrasound-guided percutaneous core needle biopsy in anterior mediastinal masses

Objective

To evaluate the efficacy and safety of percutaneous core needle biopsy (PCNB) using ultrasound (US)-guided and contrast-enhanced ultrasound (CEUS)-guided procedures for anterior mediastinal masses (AMMs).

Methods

In total, 284 consecutive patients (166 men, 118 women; mean age, 43.0 ​± ​18.4 years) who underwent PCNB for AMMs were enrolled. Patients were divided into the US-guided group (n ​= ​133) and the CEUS-guided group (n ​= ​151). PCNB was performed using a core needle (16-gauge or 18-gauge). Internal necrosis, diagnostic yield, and diagnostic accuracy were compared between the two groups.

Results

The predominant final diagnosis of the cases in this study was thymoma (29.7%), lymphoma (20.5%), thymic carcinoma (13.3%), and germ cell tumour (13.3%), respectively. There was no significant difference in patient age, sex, number of percutaneous biopsies, or display rate of internal necrosis on conventional US between the two groups. The rate of internal necrosis of the lesions was significantly higher after contrast agent injection (72.2% vs. 41.7%; P ​< ​0.001). The CEUS-guided group had a higher diagnostic yield than the US-guided group (100% vs. 89.5%, P ​< ​0.001). There was no significant difference between the diagnostic accuracy of the CEUS-guided and US-guided groups (97.3% vs. 97.4%; P ​= ​1.000). None of the patients experienced adverse reactions or complications after US-guided or CEUS-guided PCNB.

Conclusions

CEUS-guided PCNB can improve the diagnostic yield by optimizing the biopsy procedure.

Mediastinal lymphadenopathy: a practical approach

Introduction: Mediastinal lymphadenopathy is secondary to various benign and malignant etiologies. There is a variation in the underlying cause in different demographic settings. The initial clue to the presence of enlarged mediastinal lymph nodes is through thoracic imaging modalities. Malignancy (Lung cancer, lymphoma, and extrathoracic cancer) and granulomatous conditions (sarcoidosis and tuberculosis) are the most common causes. For a confident diagnosis, the clinician must choose from several available options and integrate the clinical, radiological, and pathology findings. An accurate diagnosis is necessary for optimal management.Areas covered: We performed a search of the PUBMED database to identify relevant articles on the causes, imaging modalities, and interventional modalities to diagnose these conditions. We discuss a practical approach toward the evaluation of a patient with mediastinal lymphadenopathy.Expert opinion: Mediastinal lymphadenopathy is a commonly encountered clinical problem. Treating physicians need to be aware of the clinico-radiological manifestations of the common diagnostic entities. Selecting an appropriate tissue diagnosis modality is crucial, with an intent to use the least invasive technique with good diagnostic yield. Endosonographic modalities (EBUS-TBNA, EUS-FNA, and EUS-B-FNA) have emerged as the cornerstone to most patients' diagnosis. An accurate diagnosis translates into favorable treatment outcomes.

Usefulness of EUS-guided fine needle aspiration biopsy in the diagnosis of suspected or recurring lymphoproliferative disorders

BACKGROUND

EUS-guided fine needle aspiration biopsy (EUS-FNAB) of deep-seated lymphadenopathy is proposed to identify lymphoproliferative disorders when no superficial lesion is accessible.

METHODS

We analyzed prospectively collected data of 115 EUS-FNABs from 73 thoracic or abdomino-pelvic targets in 52 patients with suspected lymphoproliferative disorders (LPDs) between January 2005 and May 2011 from a single institution. Conventional histology and immunohistochemistry procedures were performed on samples.

RESULTS

No complications were recorded. An LPD was identified in 29 cases and ruled out in 21 cases. In 2 cases the analysis was negative, but an LPD was identified using a secondary procedure. For the identification of LPDs irrespective of subtype, this procedure has positive and negative predictive values of 100% and 91.3% respectively, with 93.6% sensitivity and 100% specificity. In 31 patients finally diagnosed with LPDs, an accurate diagnosis meeting the 2008 World Health Organization classification criteria was established in 21 (68%) cases, success being significantly associated with target size above 30 mm in multivariate analysis (odds ratio 7.47; p = 0.05).

CONCLUSION

EUS-FNAB of deep-seated lymphadenopathy with conventional morphological assessment appears to have a high diagnostic value for LPD identification and can obviate invasive surgery. A sub-classification was possible in two thirds of the cases.

Lymph node characteristics of sarcoidosis with endobronchial ultrasound

BACKGROUND

Sonographic features of lymph nodes on endobronchial ultrasound (EBUS) have been shown to be useful in prediction of malignancy in mediastinum and hilum. The aim of this study was to assess the utility of morphologic features of mediastinal and/or hilar lymph nodes obtained by EBUS in patients with sarcoidosis.

MATERIALS AND METHODS

We retrospectively reviewed the records of 224 patients with mediastinal/hilar lymph node enlargements who underwent EBUS for diagnostic purpose. The lymph nodes were characterized based on the EBUS images as follows: (1) Size; based on short-axis dimension, <1 cm or ≥1 cm, (2) shape; oval or round, (3) margin; distinct or indistinct, (4) echogenicity; homogeneous or heterogeneous, (5) presence or absence of central hilar structure, and (6) presence or absence of granular (sandpaper) appearance.

RESULTS

One hundred (24.4%) nodes exhibited indistinct margins while 309 (75.6%) had distinct margins. One hundred and ninety nine (48.7%) nodes were characterized as homogeneous, and 210 (51.3%) nodes as heterogeneous. Granular appearance was observed in 130 (31.8%) lymph nodes. The presence of granules in lymph nodes on EBUS had the highest specificity (99.3%) for the diagnosis of sarcoidosis. Logistic regression analysis revealed the finding of distinct margin alone as an independent predictive factor for the diagnosis of sarcoidosis.

CONCLUSIONS

The presence of granular appearance in lymph nodes by EBUS had the highest specificity (99.3%) for the diagnosis of sarcoidosis. Lymph nodes having distinct margins tend to suggest sarcoidosis.

Positron emission tomography imaging in sarcoidosis

Sarcoidosis is a chronic granulomatous disease of unknown origin. There are several modalities for diagnosis, staging and therapeutic management of patients with sarcoidosis. Among these, whole-body F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography is found to useful in patients with complex and multisystem forms of sarcoidosis. Other modalities include Gallium scanning, assesment of angiotensin converting enzyme levels in blood, chest radiography, mediastinoscopy etcetera.

Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) of mediastinal lesions

BACKGROUND

Mediastinal endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is a recognized diagnostic and staging procedure for non-small cell lung carcinoma (NSCLC). The aim of this study was to report the experience of mediastinal EUS in an Australian tertiary hospital.

METHODS

A retrospective review was conducted on all patients undergoing mediastinal EUS from February 2002 until August 2007 at St Vincent's Hospital, Melbourne. Data were obtained from the EUS databases at St Vincent's Hospital and patient endoscopy reports. The results of EUS-FNA were compared with final diagnosis to calculate sensitivity and specificity. Surgical pathology or long-term follow-up was used to identify false positive or negative results.

RESULTS

One hundred forty-eight mediastinal EUS procedure were performed. Males comprised 63.5% and the mean age was 64.3 (range 27-85). Referrals (47%) were from respiratory physicians and 27% were from cardiothoracic surgeons. Indications for EUS-FNA included unexplained mediastinal lymphadenopathy and/or lung lesion for investigation and staging of known NSCLC. Full data were available on 124 (83.8%) cases. Data were analysed from a subset of 112 where FNA was performed. For each indication, EUS-FNA had a high sensitivity and specificity: staging of known NSCLC (sensitivity 92.9%, specificity 88.9%), mediastinal lymphadenopathy (sensitivity 100%, specificity 100%) and lung lesion (sensitivity 94.4%, specificity 85.7%). There were no major complications.

CONCLUSION

This large series of mediastinal EUS shows that it is an important and useful tool for the assessment of mediastinal pathology. It is safe and highly accurate, and should be incorporated into the staging algorithm for NSCLC.

[Mediastinal tumors: introduction]

Mediastinal tumors are relatively uncommon, usually incidentally discovered on a chest X-ray in asymptomatic patients. Young adults are particularly concerned. Mediastinal masses represent a group of heterogeneous histological type cell. A definite diagnosis is essential leading to an adequate prompt therapeutic strategy when either benign disease or aggressive malignant tumor is conceivable. Indeed the therapeutic management of such tumors could be strictly medical, requiring exclusive surgical approach or includes a multimodal treatment. Clinical examination and imaging are important tools in the diagnostic approach. However the specific diagnosis could be complex and requires histological confirmation by an experienced pathologist after examination of large biopsies of the tumor. Several investigations, including surgical invasive exploration, should be quickly requested in order to achieve a final diagnosis and refer patients in an adequate therapeutic scheme without delay. The aim of this article is to point out the available diagnostic tools in mediastinal masses, including surgical approach, and to identify the role of surgical resection in specific subtypes.

Economic analysis of combined endoscopic and endobronchial ultrasound in the evaluation of patients with suspected non-small cell lung cancer

Lung cancer remains the most common cause of cancer-related death in the United States. This study evaluated the costs of alternative diagnostic evaluations for patients with suspected non-small cell lung cancer (NSCLC). Researchers used a cost-minimization model to compare various diagnostic approaches in the evaluation of patients with NSCLC. It was less expensive to use an initial endoscopic ultrasound (EUS) with fine needle aspiration (FNA) to detect a mediastinal lymph node metastasis ($18,603 per patient), compared with combined EUS FNA and endobronchial ultrasound (EBUS) with FNA ($18,753). The results were sensitive to the prevalence of malignant mediastinal lymph nodes; EUS FNA remained least costly, if the probability of nodal metastases was <32.9%, as would occur in a patient without abnormal lymph nodes on computed tomography (CT). While EUS FNA combined with EBUS FNA was the most economical approach, if the rate of nodal metastases was higher, as would be the case in patients with abnormal lymph nodes on CT. Both of these strategies were less costly than bronchoscopy or mediastinoscopy. The pre-test probability of nodal metastases can determine the most cost-effective testing strategy for evaluation of a patient with NSCLC. Pre-procedure CT may be helpful in assessing probability of mediastinal nodal metastases.

Diagnosis of sarcoidosis

PURPOSE OF REVIEW

To describe the recent advances in the diagnostic procedures for sarcoidosis and explore future directions.

RECENT FINDINGS

Novel imaging techniques have been explored in sarcoidosis, such as positron emission tomography using L-[3-F]-alpha-methyltyrosine, which is more specific for malignancy than F-fluorodeoxyglucose positron emission tomography. The combined modality of L-[3-F]-alpha-methyltyrosine-positron emission tomography with fluorodeoxyglucose-positron emission tomography could successfully discriminate sarcoidosis from malignancy. The finding of delayed enhancement in cardiac magnetic resonance imaging could identify cardiac involvement of sarcoidosis with higher sensitivity than echocardiography, thallium scintigraphy, and gallium scintigraphy. Endobronchial ultrasonograpy-guided transbronchial needle aspiration is a safe and useful tool for diagnosing sarcoidosis with a diagnostic accuracy, sensitivity and specificity of 85-93, 78-89, and 92-96%, respectively. Developments in genetics have demonstrated that 99% of the human leukocyte antigen DRB1*0301/DQB1*0201-positive patients with Löfgren's syndrome show a spontaneous remission, in contrast to only 55% of the human leukocyte antigen DRB1*0301/DQB1*0201-negative patients. These alleles could be novel promising factors for discriminating a prognosis in Löfgren's syndrome.

SUMMARY

Recent development including novel imaging techniques, novel biopsy procedures, and genetic analyses could be of value for the diagnosis of sarcoidosis.

Diagnosis of intra-abdominal and mediastinal sarcoidosis with EUS-guided FNA

BACKGROUND

In the presence of a compatible clinical picture, the diagnosis of sarcoidosis requires pathologic confirmation of noncaseating epithelioid granuloma in affected tissues. The standard procedure of choice for most patients is a bronchoscopy with transbronchial biopsy (TBB), which has a diagnostic yield of 40% to 90%. The lowest yield with TBB is in cases that present with predominant mediastinal or intra-abdominal lymphadenopathy (LN) and minimal parenchymal lung involvement.

OBJECTIVE

To study the diagnostic yield of EUS-guided FNA in diagnosing sarcoidosis with predominant LN or masses.

DESIGN

Retrospective chart review.

SETTING

Teaching university hospital.

PATIENTS

Analysis of 21 consecutive patients with sarcoidosis and predominant mediastinal and/or intra-abdominal LN or masses who underwent EUS-guided FNA.

RESULTS

EUS-guided FNA diagnosed sarcoidosis in 18 of 21 patients (86%). In 3 patients, EUS-guided FNA was either not diagnostic or inconclusive, and patients underwent mediastinoscopy with lymphadenectomy, which established the diagnosis of sarcoidosis. Seven of the 21 patients (33%) had intra-abdominal LN and/or masses, and EUS-guided FNA of the intra-abdominal pathology was diagnostic of sarcoidosis in 4 of the 7 patients (57%). Four of the 21 patients (19%) had a history of malignancy, and use of EUS-guided FNA helped in ruling out the recurrence of malignancy in 3 of the 4 patients (75%).

LIMITATIONS

Mycobacterial and fungal culture was not obtained in all patients.

CONCLUSIONS

EUS-guided FNA offers a practical, minimally invasive technique for the diagnosis of sarcoidosis in patients who present with predominant mediastinal and/or intra-abdominal LN or masses.

Endobronchial ultrasound for the diagnosis of pulmonary sarcoidosis

BACKGROUND

The diagnosis of pulmonary sarcoidosis can be established by a variety of techniques. Transbronchial lung biopsy is often the preferred approach, but it is frequently nondiagnostic and carries a risk of pneumothorax and bleeding. Mediastinoscopy is often suggested as the next diagnostic step but entails significant cost and associated morbidity. Endobronchial ultrasound (EBUS) with transbronchial needle aspiration (TBNA) is emerging as a safe, minimally invasive tool for the primary diagnosis of mediastinal and hilar lymphadenopathy. The purpose of this study was to assess the utility of EBUS-TBNA for pulmonary sarcoidosis.

METHODS

Fifty consecutive patients who had been referred for EBUS-TBNA for suspected pulmonary sarcoidosis were included in the study. On-site cytology was used to assess the adequacy of the samples. The presence of noncaseating granulomas without necrosis in the appropriate clinical setting was deemed to be adequate for the diagnosis of pulmonary sarcoidosis. Patients with a negative EBUS-TBNA underwent further histologic biopsy or clinical follow-up to determine the final diagnosis.

RESULTS

Eighty-two lymph nodes with a median size of 16 mm (range, 4 to 40 mm) were punctured. EBUS-TBNA demonstrated noncaseating granulomas without necrosis in 41 of 48 patients (85%) with a final diagnosis of sarcoidosis. EBUS-TBNA, therefore, has a sensitivity of 85% for the primary diagnosis of pulmonary sarcoidosis.

CONCLUSIONS

EBUS-TBNA is a safe, minimally invasive tool for the primary diagnosis of pulmonary sarcoidosis that has a high diagnostic yield. EBUS-TBNA should be considered an appropriate alternative diagnostic technique for patients with suspected pulmonary sarcoidosis.

Long-term effects of thoracic sympathectomy on microcirculation in the hands of patients with primary Raynaud disease

OBJECTIVE

Videothoracoscopic sympathecomy is a widely used treatment modality in patients with severe Raynaud disease, but the reported late results are less than favorable. There have been no direct studies of the long-term effect of sympathectomy on microcirculation in the hands of these patients.

METHODS

In 25 patients with Raynaud disease treated with videothoracoscopic Th2-Th4 sympathectomy, we performed basal laser-Doppler flowmetry and measured the maximal refilling time after 1-minute occlusion measurements preoperatively and at 1 week, 6 months, and 1, 2, 3, and 5 years after the sympathectomy. The results were compared with the same measurements obtained in the group of 50 healthy individuals.

RESULTS

The patients' symptom severity was assessed by using the visual analogue scale. The basal capillary flow and the maximal refilling time improved after the sympathectomy to a level not different from that seen in the healthy population, and the effect was maintained during the 5-year follow-up period. The patients' symptom severity scores diminished to zero in the early postoperative period and increased to 28% of their initial value 5 years after the operation.

CONCLUSIONS

The videothoracoscopic Th2-Th4 sympathectomy produces excellent and long-lasting improvement of microcirculation function in patients with Raynaud disease. The mild return of symptoms might be due to factors other than the capillary blood flow alterations.

The Wider Scope of Video-Assisted Thoracoscopic Surgery

In the past, rudimentary devices were used to look closely into the chest; currently, advanced video technology, computers, and high-tech electronics are being used to perform many surgical procedures that formerly required a large, open incision. The goal of video-assisted thoracoscopic surgery (VATS) is the same as for comparable open procedures, but it is accomplished with less pain, less patient morbidity, and a shorter hospital stay. In addition to evaluating and treating thoracic injuries, VATS has demonstrated effectiveness in detecting and managing many other conditions, such as pleural disease, interstitial lung disease, and thoracic malignancies.

Staging and diagnosis of non-small cell lung cancer: Invasive modalities

During the staging process of lung cancer, accurate mediastinal lymph node staging is one of the more important factors that affects patient outcome. Several different invasive and non-invasive modalities exist for mediastinal staging. Invasive tests include mediastinoscopy, thoracoscopy, transbronchial needle aspiration, transthoracic needle aspiration, endoscopic ultrasound-guided fine-needle aspiration and endobronchial ultrasound-guided transbronchial needle aspiration. Each of the invasive tests has limitations for particular locations, has particular risks and requires specific skills. Invasive tests are often used to confirm the staging of lung cancer, but are also used to obtain a diagnosis. The best approach depends upon the clinician's assessment of the patient. This review discusses the invasive staging tests that are available, with particular emphasis on newer modalities, especially endobronchial ultrasound-guided transbronchial needle aspiration. In addition, the current advances in diagnostic bronchoscopy for lung cancer will be reviewed.

CURRENT CLINICAL APPLICATIONS OF ENDOSCOPIC ULTRASOUND

Endoscopic ultrasound (EUS) has been developed since the early 1980s. Its clinical role in the diagnosis of gastrointestinal wall lesions and staging of gastrointestinal and lung cancer has evolved over the last two decades. Initially, it was either used as an imaging tool for gastrointestinal wall lesions or for staging of gastrointestinal tumours. However, in combination with fine-needle aspiration under real-time scanning, EUS is now being used in tissue sampling for diagnosis. In addition, EUS may be used therapeutically in coeliac plexus neurolysis or pseudocyst drainage. This review concentrates on the current applications of EUS.

Diagnostische videoassistierte Thorakoskopie

Modern radiologic diagnostics show a variety of pathological changes in the mediastinum, pleura, and lung but no evidence on their histogenesis. Transbronchial and transthoracal fine-needle aspiration biopsy usually cannot yield detailed diagnostic results because of its small size. Sufficient and representative material can be obtained by thoracoscopy. Video-assisted thoracoscopy allows safe and fast diagnosis of diffuse lung diseases, pleural diseases including malignant mesothelioma, indeterminate peripheral lung nodule, and mediastinal masses. This gentle diagnostic method can give invaluable information guiding further management of the thoracic injury. Video-assisted thoracoscopy is a safe and effective guiding tool if performed by experienced thoracic surgeons able to convert to thoracotomy. It is to be noted that interpretation of intraoperative findings plays a decisive role in interdisciplinary diagnostics of intrathoracal diseases.

Manifestations neuro-ophtalmologiques révélatrices d’une neuro-sarcoïdose

PURPOSE

To describe different forms of neuro-ophthalmologic onset of sarcoidosis: clinical signs, means of diagnosis, treatment, and progression.

PATIENTS AND METHODS

Retrospective study of 13 patients with neuro-ophthalmologic initial onset of sarcoidosis diagnosed in three departments between 1997 and 2003.

RESULTS

There were ten women and three men, with a mean age of 36 years. Six patients suffered from diplopia. In three cases, the cavernous sinus was involved; the three other patients with diplopia had meningoradiculitis. Nine patients had infiltration of the anterior visual pathway: the optic nerve was involved in five cases, the chiasm in two cases, and two patients had papilledema. Two patients also had both symptoms. The dosage of the angiotensin-converting enzyme level was evaluated in 11 patients and was elevated in six cases. Nine patients underwent a lumbar puncture; the cerebrospinal fluid protein was high in seven cases. Chest radiography and CT were abnormal in nine cases of 11. Ten patients had histological proof of sarcoidosis; the three others had enough evidence to support this diagnosis. All of them were treated with systemic corticosteroids. The diplopia improved for the six patients. Among the seven patients with optic nerve or chiasmal infiltration, one recovered completely, two were partially improved, and four remained stable.

CONCLUSIONS

Diplopia and anterior visual pathway abnormalities can be the manifestation of initial onset of sarcoidosis; therefore this diagnosis must be kept in mind when these frequent neuro-ophthalmologic signs are encountered. Complementary exams, mainly biopsy of the involved areas with histological analysis, are needed to confirm this diagnosis. Corticosteroid treatment is generally followed by improvement, but relapses may occur.

Real-time Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration of Mediastinal and Hilar Lymph Nodes

STUDY OBJECTIVES

Although various techniques are available for obtaining pathology specimens from the mediastinal lymph nodes, including conventional bronchoscopic transbronchial needle aspiration (TBNA), transesophageal ultrasonography-guided needle aspiration, and mediastinoscopy, there are limitations to these techniques, which include low yield, poor access, need for general anesthesia, or complications. To overcome these problems, we undertook the current study to evaluate the clinical utility of the newly developed ultrasound puncture bronchoscope to visualize and perform real-time TBNA of the mediastinal and hilar lymph nodes under direct endobronchial ultrasonography (EBUS) guidance.

DESIGN

Prospective patient enrollment.

SETTING

University teaching hospital.

PATIENTS

From March 2002 to September 2003, 70 patients were included in the study.

INTERVENTIONS

The new convex probe (CP) EBUS is integrated with a convex scanning probe on its tip with a separate working channel, thus permitting real-time EBUS-guided TBNA. The indications for CP-EBUS were the diagnosis of mediastinal and/or hilar lymphadenopathy for known or suspected malignancy. Lymph nodes and the surrounding vessels were first visualized with CP-EBUS using the Doppler mode. The dimensions of the lymph nodes were recorded, followed by real-time TBNA under direct EBUS guidance. Final diagnosis was based on cytology, surgical results, and/or clinical follow-up.

RESULTS

All lymph nodes that were detected on the chest CT scan could be visualized using CP-EBUS. In 70 patients, CP-EBUS-guided TBNA was performed to obtain samples from mediastinal lymph nodes (58 nodes) and hilar lymph nodes (12 nodes). The sensitivity, specificity, and accuracy of CP-EBUS-guided TBNA in distinguishing benign from malignant lymph nodes were 95.7%, 100%, and 97.1%, respectively. The procedure was uneventful, and there were no complications.

CONCLUSIONS

Real-time CP-EBUS-guided TBNA of mediastinal and hilar lymph nodes is a novel approach that is safe and has a good diagnostic yield. This new ultrasound puncture bronchoscope has an excellent potential for assisting in safe and accurate diagnostic interventional bronchoscopy.

Efficacy and safety of single-trocar technique for minimally invasive surgery of the chest in the treatment of noncomplex pleural disease

OBJECTIVE

To assess the efficacy and the safety of a single-trocar technique for minimally invasive surgery of the chest in the management of multiple noncomplex thoracic diseases, a prospective study was performed and the results are presented.

METHODS

Between October 1998 and December 2001, 100 patients underwent video-assisted thoracic surgery through a single trocar. The patients were divided into 4 groups as follows: (1) benign, (2) malignant, (3) pleural effusion, and (4) empyema. The following data were analyzed: age, sex, forced vital capacity, forced expiratory volume in 1 second, percentage of the predicted forced expiratory volume in 1 second, type of anesthesia, anesthesia time, surgery time, intraoperative complications, morbidity, chest tube removal, hospital stay, and follow-up.

RESULTS

The patient population consisted of 64 men and 36 women with a mean age of 62 years (range 31-92 years). General anesthesia was used in 53 patients (25 double-lumen and 28 single-lumen tube) and local anesthesia and sedation in 47 patients. Talc pleurodesis was performed in 55 patients. Mean operative time was 65 +/- 37 minutes, 48 +/- 18 minutes for simple and 67 +/- 37 minutes (P =.004) for complex pleural effusion. Mean anesthesia time was 102 +/- 85 minutes. Chest tubes were removed after 5 +/- 2 days. Mean overall hospital stay was 6 +/- 3 days, 5 +/- 2 days for benign diseases, 7 +/- 3 days for malignant diseases, and 8 +/- 3 for empyema. Morbidity was present in 19 patients. Two patients had intraoperative bleeding; 1 required a mini-thoracotomy to control it. There was no hospital mortality. Three patients had wound infection, and no patient with malignant diseases had port site metastasis.

CONCLUSION

Video-assisted thoracic surgery through a single trocar is simple, effective, and beneficial for all patients in the diagnosis and treatment of noncomplex diseases of the chest. Furthermore, with this newest type of technologically advanced instrumentation it is possible to carry out simple intrathoracic procedures without using additional ports.

Current concepts in the staging of non-small cell lung cancer

When evaluating a patient diagnosed with non-small cell lung cancer (NSCLC), staging helps define the extent of disease. The main goals of staging are to assist in determining appropriate treatment options (surgery versus non-surgical) and in predicting prognosis. Based on the recommendation of the American Joint Committee for Cancer (AJCC), a TNM (tumor, node, and metastases) staging system is used for NSCLC. Clinical staging (cTNM) is determined using non-invasive techniques such as clinical assessment and radiologic testing. Pathologic staging (pTNM) is determined using invasive techniques such as bronchoscopy, mediastinoscopy, and video-assisted thoracoscopic surgery, or at the time of thoracotomy. Recently, new staging modalities such as positron emission tomography and intraoperative sentinel node mapping have been used with promising results. In the near future, these techniques, as well as molecular and serum tumor markers, will likely be used to more accurately determine the burden of disease and allow for more appropriate treatment.

Clinical utility of EUS-guided fine-needle aspiration of mediastinal masses in the absence of known pulmonary malignancy

BACKGROUND

Mediastinal masses represent a diagnostic challenge because of their proximity to numerous critical structures, difficulty of access for tissue sampling, and myriad potential pathologic etiologies. A large, single-center experience with EUS-guided fine-needle aspiration (EUS-FNA) in the diagnosis of non-lung cancer-related mediastinal masses is presented.

METHODS

An EUS database was reviewed and all cases of mediastinal mass or lymphadenopathy encountered between 1994 and 1999 were included. Final diagnoses were determined by EUS-FNA cytology and clinical follow-up.

RESULTS

Forty-nine patients were identified (27 women, 22 men; mean age 58.1 years, range 30-89 years). A malignant process was diagnosed in 22 cases (45%) and a benign process in 24 (49%). The EUS-FNA specimen was nondiagnostic in 3 cases (6%). An accurate diagnosis was made in 46 of the 49 patients (94%). No complication was noted.

CONCLUSIONS

EUS-FNA is a minimally invasive technique that facilitates detection and tissue sampling of mediastinal masses. It is a safe procedure that can be performed with the patient under conscious sedation in an outpatient setting.

[Multicenter experience of video-assisted thoracic surgery to treat mediastinal cysts and tumors]

OBJECTIVE

In spite of improvements in imaging techniques, surgical procedures are often needed to diagnose and definitively treat mediastinal masses. The range of application of video-assisted thoracic surgery (VATS) in this context is still poorly defined. The present study describes and analyzes the experience of the Cooperative Group for Video-assisted Thoracoscopic Surgery of the Spanish Society of Pneumology and Thoracic Surgery (GCCVT-SEPAR), with the aim of determining the usefulness of the technique for treating mediastinal cysts and tumors.

METHOD

For 2 years we gathered information prospectively on 1,573 consecutive VATS procedures in 17 hospitals. The data from 64 procedures performed for diagnosis and treatment of mediastinal cysts and tumors are analyzed.

RESULTS

A definitive diagnosis was reached in all cases. Nineteen were malignant tumors and 45 were benign lesions. Twenty-five complete resections (39%) were performed: 6 pleuropericardial cysts, 4 bronchogenic cysts, 8 neurogenic tumors and other benign lesions. Radiologically poorly defined masses and those located in the anterior and median parts of the mediastinum were most often the object of diagnostic procedures, whereas cysts and well-defined solid lesions on the posterior mediastinum were usually the object of therapeutic interventions. Eleven percent of the cases required conversion to thoracotomy, mainly due to pleural adhesions. Four complications (6.3%) were recorded and no deaths occurred. The median hospital stay after surgery was 2.5 days; 7.8% of the procedures were performed on outpatients.

CONCLUSIONS

VATS is performed on many mediastinal lesions in Spain. Cysts and benign tumors are selected for resection. Poorly defined and malignant lesions were diagnosed by biopsy. The experience reported demonstrates the efficacy and safety of this technique for selected cases.

Cost-minimization analysis of alternative diagnostic approaches in a modeled patient with non-small cell lung cancer and subcarinal lymphadenopathy

OBJECTIVE

To evaluate the costs of alternative diagnostic evaluations of enlarged subcarinal lymph nodes (SLNs) in modeled patients with non-small cell lung cancer (NSCLC).

METHODS

A cost-minimization model was used to compare 5 diagnostic approaches in the evaluation of enlarged SLNs in modeled patients with NSCLC. Values for the test performance characteristics and prevalence of malignancy in patients with SLN were obtained from the medical literature. The target population was adult patients known or suspected to have NSCLC with SLNs with a short axis length of at least 10 mm on thoracic computed tomography (CT).

RESULTS

The lowest-cost diagnostic work-up was by initial evaluation with endoscopic ultrasonography-guided fine-needle aspiration (EUS FNA) biopsy ($11,490 per patient) compared with mediastinoscopy (with biopsy) ($13,658), transbronchial FNA biopsy ($11,963), CT-guided FNA biopsy ($13,027), and positron emission tomography ($12,887). The results were sensitive to rate of SLN metastases and EUS FNA sensitivity. The EUS FNA biopsy remained least costly if the probability of SLN metastases exceeded 24% or EUS FNA sensitivity was higher than 76%. Primary mediastinoscopy was the most economical if not.

CONCLUSIONS

Which testing strategy is least costly for SLN evaluation in a modeled patient with NSCLC may be determined by the pretest probability of nodal metastases. Use of EUS FNA biopsy minimizes the cost of diagnostic evaluation in most cases.

Thoracoscopy or CT-guided biopsy for residual intrathoracic masses after treatment of lymphoma

BACKGROUND

An intrathoracic mass persists after completion of treatment in 20% of the patients treated for Hodgkin's disease (HD) or non-Hodgkin's lymphoma (NHL). Gallium scan and positron emission tomography allow for diagnosis in most cases. However, in some patients, a pathologic examination of the residual mass (RM) is required. The aim of this study was to evaluate the results of a thoracoscopic approach for intrathoracic RM, as compared with image-guided biopsies.

PATIENTS AND METHODS

From 1996 to 1998, 29 consecutive patients treated for NLH (n = 11) or HD (n = 18) were referred either to radiology (group R; n = 8) or to surgery (group S; n = 21) for biopsy of an intrathoracic RM. There were 13 male and 16 female patients ranging in age from 15 to 56 years (mean, 32 years). The reason for a biopsy was the inability to determine the nature of the RM by means of radiologic examination or scintigraphy. Biopsy was defined as successful when (1) residual lymphoma was found in the specimen, or (2) benign tissue was found and the patient remained disease-free after a minimal follow-up period of 12 months. A biopsy was defined as a failure when a local recurrence occurred in a patient with a diagnosis of benign lesion.

RESULTS

No significant procedure-related complications occurred in either group. The mean follow-up was 26 months (range, 13 to 72 months). In group R, residual lymphoma was found in only one patient. In group S, residual lymphoma was found in seven patients (p = 0.5). In the seven patients of group R with a diagnosis of benign mediastinal lesion, two patients had a local recurrence and one had a recurrence within the abdomen. In the 15 patients of group S in whom no residual disease was found, 1 patient had an intrathoracic recurrence (p = 0.5) while 2 patients had recurrence in a remote site.

CONCLUSION

Despite the limited number of patients in this series, results suggest that a thoracoscopic approach yields better data than image-guided biopsies.

Is there a role for routine mediastinoscopy in patients with peripheral T1 lung cancers?

BACKGROUND

The role of surgical staging of patients with non-small cell lung cancer (NSCLC) continues to evolve. This report describes our findings utilizing routine cervical mediastinoscopy in the evaluation of peripheral T1 (<3 cm) lung tumors.

METHODS

Retrospectively 30 patients with peripheral T1 lesions and CT scans negative for pathologic adenopathy were identified over a 3-year period. Cervical mediastinoscopy was performed prior to VATS/thoracotomy during the same operative session.

RESULTS

Mediastinoscopy was performed in 29 of 30 patients. For patients with malignancy (27 of 30), 3 of 27 (11%) had mediastinoscopy positive for malignancy and no further resection performed. Overall the subgroup of patients with bronchogenic carcinomas had positive mediastinal involvement identified in 5 of 24 (21%) after mediastinoscopy or complete resection.

CONCLUSION

A significant number of patients with small peripheral lung cancers harbor radiographically occult lymph node involvement. Mediastinoscopy facilitates identification of patients with regionally advanced disease prior to resection, allowing neoadjuvant therapy and avoiding unnecessary resections.

Video-assisted thoracic surgery for diseases within the mediastinum

VATS and concepts of minimal access thoracic surgery have revitalized many aspects of general thoracic surgery, including the surgical approach to diseases and conditions of the mediastinum. Proven surgical options that have been shunned by patients and referring physicians because of the perceived morbidity of thoracotomy have been reconsidered with the emergence of these minimal access surgical options. Continued critical review of the accumulating experience in VATS techniques will refine the surgical indications for VATS and open thoracotomy.

Diagnosis and treatment of mediastinal tumors by thoracoscopy

OBJECTIVES

Thoracoscopic management of mediastinal tumors is still subject to analysis. Seventy-three patients underwent thoracoscopy for treatment of mediastinal masses and were analyzed retrospectively in order to evaluate the effectiveness and complications of the procedure.

METHODS

Between 1983 and 1999, 21 conventional thoracoscopies and 52 video-assisted thoracic surgeries were performed (33 for diagnostic purposes and 40 for therapy). Patient ages ranged from 2 to 81 years (mean, 43.8 years) with a slight predominance of girls and women over men and boys (41 vs 32, respectively). All patients underwent general anesthesia using simple intubation (22 patients) or double-lumen intubation (51 patients).

RESULTS

The histologic type of tumors was obtained in all patients. For therapeutic purposes, a change of procedure to thoracotomy was necessary in nine patients. The reasons for this change were tumor size, tumor invasion of nearby structures, difficulties in continuing the dissection, the performance of an upper lobectomy, and suturing the iatrogenic lesion of the diaphragm. Four patients died during the first 30 postoperative days as a consequence of their primary pathology.

CONCLUSION

Thoracoscopy was confirmed as an effective diagnostic and therapeutic alternative for the treatment of mediastinal disorders.

The current role of mediastinoscopy in the evaluation of thoracic disease

OBJECTIVE

Mediastinoscopy is a common procedure used for the diagnosis of thoracic disease and the staging of lung cancer. We sought to determine the current role of mediastinoscopy in the evaluation of thoracic disease.

METHODS

We conducted a retrospective review of all mediastinoscopies performed by members of our service between January 1988 and September 1998.

RESULTS

We performed mediastinoscopies on 2137 patients. A total of 1745 patients underwent mediastinoscopy for known or suspected lung cancer. In 422 of these procedures, N2 or N3 disease was identified; only 28 of these patients underwent resection. The remaining 1323 had no evidence of metastatic disease. In these patients 947 had lung cancer. Only 76 of the patients with lung cancer were found to have N2 disease at exploration. Among the 1323 patients with a negative mediastinoscopy result, 52 underwent resection of a nonbronchogenic malignancy, and 217 had resection of a benign lesion. A total of 392 patients underwent mediastinoscopy for the evaluation of mediastinal adenopathy in the absence of any identifiable pulmonary lesion. Of these, 161 had a nonbronchogenic malignancy, 209 had benign disease, and 25 had no diagnosis established; mediastinoscopy established a definitive diagnosis in 93.6% of patients. In the entire group of 2137 patients, there were 4 perioperative deaths and 12 complications. Only one death was directly attributed to mediastinoscopy. No deaths or complications occurred in patients undergoing mediastinoscopy for benign disease.

CONCLUSIONS

Mediastinoscopy is a highly effective and safe procedure. We believe that mediastinoscopy should currently be used routinely in the diagnosis and staging of thoracic diseases.

The role of thoracic surgery in diagnosing interstitial lung disease

In this article, the current status of thoracic surgery options for reaching a diagnosis in interstitial lung disease is described. When surgery is needed, mediastinoscopy is the first step in cases of suspected stage I or II sarcoidosis. If this is not the case, video-assisted thoracoscopy is currently preferred to open lung biopsy because the need for analgesia lessened, less blood is lost, the operative time is shorter, the complication rate is lower, and the postoperative stay is shorter. In some cases, video-assisted thoracoscopy may also be preferred to mediastinoscopy, especially in young women, for cosmetic reasons.

Diagnosis of mediastinal masses in pediatric patients using mediastinoscopy and the Chamberlain procedure

BACKGROUND/PURPOSE

Mediastinal masses commonly are referred to the pediatric surgeon and can be difficult diagnostic problems. Various techniques have been used to perform biopsy in the mediastinum, but there are few reports of mediastinoscopy or Chamberlain procedure in children in the literature. The authors reviewed their experience with these techniques in a pediatric oncology population.

METHODS

The medical records of all patients on the pediatric surgical service between 1987 and 1997, inclusive, who underwent mediastinoscopy or Chamberlain procedure were reviewed. Demographic data, diagnostic accuracy, complications, operating time, and blood loss were recorded.

RESULTS

Sixteen consecutive patients underwent 13 Chamberlain procedures and six mediastinoscopies over the above period. Diagnostic accuracy was found to be 95% overall (100% for Chamberlain procedure, 83% for mediastinoscopy). Five complications occurred in the Chamberlain group and none in the mediastinoscopy group. No complication required thoracotomy or sternotomy. Among patients whose sole reason for admission was diagnosis of a mediastinal mass, the mean hospital stay was 1.7+/-0.8 days (n = 7) for those who underwent Chamberlain procedure and 1.4+/-0.9 days (n = 4) for those who underwent mediastinoscopy. One mediastinoscopy was performed as an ambulatory procedure.

CONCLUSION

Mediastinoscopy and the Chamberlain procedure are effective and safe techniques for biopsy of mediastinal masses in this age group.

Surgical endoscopic techniques in the diagnosis and follow-up of patients with lymphoma

BACKGROUND

In patients with lymphoma, tissue for histology can be obtained through image-guided techniques or by surgery. The aim of this study was to assess the efficacy of surgical endoscopic techniques in obtaining adequate tissue specimens.

METHODS

Ninety-two patients with suspected or confirmed lymphoma were referred for a surgical biopsy of a deeply located intrathoracic or intra-abdominal mass or lymph node. The 86 patients who had surgery using a surgical endoscopic technique were included in this study. There were 54 men and 32 women, of mean age 34 (range 15-78) years. Most were selected directly for surgery while five previously had a failed computed tomography-guided biopsy. A total of 89 procedures were performed in 86 patients: laparoscopy (15 patients), thoracoscopy (61) and mediastinoscopy (13).

RESULTS

No patient died. One intraoperative complication occurred during thoracoscopy (1 per cent). Two postoperative complications were noted (2 per cent). Three patients required conversion to open surgery (3 per cent). Adequate tissue for histology was obtained by surgical endoscopic procedures in 87 per cent. Twelve of 13 mediastinoscopies were successful. After thoracoscopy, the success rate was 92 per cent but only nine of 15 laparoscopies were considered successful.

CONCLUSION

In patients with lymphoma, surgical endoscopic techniques have a high diagnostic yield and a low morbidity rate. Barring exceptional circumstances these should be favoured rather than conventional open surgery.