MEDIASTINAL EXPLORATION BY THE TECHNIQUE OF CARLENS

Assessment of Operability and Resectability in Lung Cancer

Lung cancer is a lethal disease, and chronic cigarette smoking is the most common cause. The selection of treatment is based on the histologic cell type, accurate staging, and adequacy of cardiopulmonary functional reserve. The risk for surgery is highest in patients over the age of 80 years.

Diagnosis and Detection of Sarcoidosis. An Official American Thoracic Society Clinical Practice Guideline

Background: The diagnosis of sarcoidosis is not standardized but is based on three major criteria: a compatible clinical presentation, finding nonnecrotizing granulomatous inflammation in one or more tissue samples, and the exclusion of alternative causes of granulomatous disease. There are no universally accepted measures to determine if each diagnostic criterion has been satisfied; therefore, the diagnosis of sarcoidosis is never fully secure.

Methods: Systematic reviews and, when appropriate, meta-analyses were performed to summarize the best available evidence. The evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation approach and then discussed by a multidisciplinary panel. Recommendations for or against various diagnostic tests were formulated and graded after the expert panel weighed desirable and undesirable consequences, certainty of estimates, feasibility, and acceptability.

Results: The clinical presentation, histopathology, and exclusion of alternative diagnoses were summarized. On the basis of the available evidence, the expert committee made 1 strong recommendation for baseline serum calcium testing, 13 conditional recommendations, and 1 best practice statement. All evidence was very low quality.

Conclusions: The panel used systematic reviews of the evidence to inform clinical recommendations in favor of or against various diagnostic tests in patients with suspected or known sarcoidosis. The evidence and recommendations should be revisited as new evidence becomes available.

Comparison of biopsy procedures in intrathoracic sarcoidosis

A series of 78 patients, mainly young males, with intrathoracic manifestations of sarcoidosis, found on routine chest X-ray, were examined according to a prescheduled program including different biopsy procedures. In 76% the intrathoracic changes were isolated hilar adenopathy, in 9% isolated pulmonary lesions and in 15% hilar adenopathy plus pulmonary lesions. Lymph nodes containing granulomas were found by mediastinoscopy in 41 of 44 patients and by scalene fat pad biopsy in 20 of 34 patients. In 27 of 76 patients granulomas were found by liver biopsy. Complications to the biopsies were more frequent with mediastinoscopy than with the other two biopsy procedures, but no serious complications occurred. Biopsy through mediastinoscopy is thus preferable in patients of this kind. The necessity of doing biopsies to support the diagnosis of sarcoidosis is discussed on the basis of the literature and our own studies. In younger patients with asymptomatic, bilateral hilar adenopathy without pulmonary lesions it seems justifiable to omit biopsy, whereas biopsy is mandatory in patients with unilateral hilar lymph adenopathy and patients with pulmonary lesions. In all cases the course of the disease should be followed for a rather long period.

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.

Early detection of mediastinal spread of pulmonary carcinoma by mediastinoscopy

To the great disappointment of all concerned, too many operations performed for pulmonary carcinoma still prove to be exploratory thoracotomies or non-curative resections, in spite of careful preoperative investigations.

A follow-up study of 168 patients operated upon for pulmonary carcinoma clearly shows that such non-curative procedures yield very disappointing results.

To reduce this number of unnecessary and often harmful operations mediastinoscopy was introduced as an aid in detecting mediastinal spread of the tumour. It was thought that such knowledge would make preoperative assessment more accurate and so make easier the decision whether to operate.

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.