Ann Thorac Surg 2002;73:250-252
© 2002 The Society of Thoracic Surgeons
Original article: general thoracic
Extended cervical mediastinoscopy in the diagnosis of anterior mediastinal masses
Muzaffer Metin, MDa,
Adnan Sayar, MDa,
Akif Turna, MD*a,
Atilla Gürses, MDa
a Yedikule Hospital for Chest Disease and Thoracic Surgery, Zeytinburnu, Istanbul, Turkey
Accepted for publication July 30, 2001.
* Address reprint requests to Dr Turna, Cami Sok. Muminderesi Yolu. Emintas Camlik Sit. No:32/22, Sahrayicedid, Kadikoy 81080 Istanbul, Turkey
e-mail: aturna{at}turk.net
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Abstract
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Background. Although transthoracic needle biopsy (TNB) has been the preferred method for the diagnosis of anterior mediastinal masses, it has inherent limitations in accuracy. In particular, lymphoma and thymoma are diagnosed less reliably using needle biopsy. Videothoracoscopy has been advocated as an alternative method for diagnosis. Our goal was to assess the usefulness of extended cervical mediastinoscopy (ECM) in the diagnosis of anterior mediastinal masses.
Methods. The ECM technique was performed in 9 patients in whom TNB and Tru-cut biopsies had been inefficient for histologic diagnosis. All lesions were in the anterior mediastinum. Extended cervical mediastinoscopy was carried out using the same incision as in a standard cervical mediastinoscopy and dissection was performed behind the sternum as previously published. Mean operative time was 50 minutes (range 40 to 70 minutes) and mean hospital stay was 8 hours (range 5 to 36 hours).
Results. Diagnosis of lymphoma in 4 cases, thymoma in 3 cases, and thymic hyperplasia in 2 cases were obtained by ECM. In 1 of 2 patients with suspected thymoma who underwent resectional surgical procedures, final histologic diagnosis was non–small cell lung carcinoma. There was no surgical mortality or intraoperative complication. One patient had minimal pneumothorax requiring no intervention.
Conclusions. We conclude that ECM in the diagnosis of anterior mediastinal masses is technically feasible and provides an alternative to the conventional approaches in patients with paraaortic or aortopulmonary masses.
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Introduction
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Various methods of treating numerous types of anterior mediastinal neoplasms are undergoing refinements; however, before the commencement of any treatment, an accurate histologic diagnosis must be established [1]. Transthoracic needle biopsy (TNB) has been approved as the main tool in diagnosing anterior mediastinal masses. However, sensitivity of TNB was reported to be as low as 20% or 71% in patients with Hodgkin disease or thymoma, respectively [2]. The size of the biopsy specimen correlates with the diagnostic accuracy. Watanabe and colleagues [3] reported that diagnostic accuracy was significantly higher in mediastinotomy biopsies than in needle biopsies.
The possibility of anterior mediastinal biopsy through cervical incision was first mentioned by Specht in 1965 [4] and "extended cervical mediastinoscopy" (ECM) was first performed by Kirschner in 1971 [5]. The operation was shown to be diagnostic for anterior mediastinal lymphadenopathies in the aortopulmonary window and subaortic region. The ECM, modified by Ginsberg and coworkers [6] and Lopez and coworkers [7] has been demonstrated to be effective in staging the subaortic and paraaortic nodes in patients with non–small cell lung cancer. Although those lesions could be sampled using TNB, mediastinotomy, or thoracoscopy, we hypothesized that ECM could offer a diagnostic yield in patients with anterior mediastinal masses. In the present study, correct identification of the nature of the anterior mediastinal masses was achieved by ECM in patients who had previously undergone TNBs, the results of which were nondiagnostic.
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Material and methods
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We retrospectively evaluated 9 patients who had undergone ECM after nondiagnostic TNB with or without Tru-cut biopsies for anterior mediastinal masses in patients with no known malignancy from March 1998 to January 2001. For radiologic evaluation, a third-generation computed tomography scan was carried out, with serial cuts of 1 cm thick from the apex of the thorax to diaphragmatic domes. The ECM technique was performed under general anesthesia, using suprasternal notch incision as in cervical mediastinoscopy after the same technique, as has been published previously [7].
The technique consisted of a dissection through a 3-cm cervical suprasternal incision (the same incision as the cervical mediastinoscopy) of the retrosternal space. A dissection was made between the anterior face of the left innominate vein and the posterior face of the sternum, separating the fascia lying between both structures. This technique allows entry at the level of the aortic arch at the origin of the innominate artery. The presence of preaortic mass was ascertained, first by feeling. The mediastinoscope was then passed by sliding it along the left anterolateral face of the aortic arch until it reached the subaortic space (aortopulmonary window).
The existing lesion at this location and all neighboring areas suspected of harboring diseases were sampled using mediastinoscopy forceps. In most of the patients, the adequacy of the samples had been confirmed by the pathologist. After biopsy, the skin was closed with a nonabsorbable subcutaneous suture. The patient was usually discharged from the hospital at the same day of the procedure.
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Results
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Of the 9 patients in our study, 7 were men. The mean age was 32 years (range 17 to 52 years) (Table 1).
All patients had undergone inconclusive diagnostic TNB with or without Tru-cut biopsies. Biopsies obtained from ECM revealed lymphoma in 4 patients, thymoma in 3, and thymic hyperplasia in 2. Patients with lymphoma were referred to an oncology department. Clinical characteristics and histologic diagnoses are provided in Table 1. Figure 1
shows a computed tomography scan of a typical anterior mediastinal mass diagnosed as thymoma using ECM. Thymic resections through median sternotomy were performed in patients with thymoma. Pathology revealed non–small cell lung carcinoma in 1 patient. Thus, ECM provided true histologic diagnosis in 8 of 9 patients.
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Fig 1. Computed tomographic scan showing anterior mediastinal mass (arrow). Pathology of the biopsy revealed a lymphoma.
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The mean duration of operation was 50 minutes (range 40 to 70 minutes) and the mean hospital stay was 8 hours (range 5 to 36 hours). There was no mortality and only 1 patient had partial pneumothorax, but the condition required no intervention.
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Comment
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Transthoracic needle biopsy has been reported to be a safe procedure to accurately obtain pretreatment histologic diagnosis in patients with mediastinal masses [1]. True positivity was reported to be as high as 91% [1]. However, the sensitivity of TNB was reported to be as low as 20% in patients with Hodgkin disease and 71% in patients with thymoma [2].
Harken and colleagues [8] performed the first paratracheal lymph node biopsy using a laryngoscope proceeding below the scalene triangle. Carlens [9] introduced cervical mediastinoscopy (SCM) allowing paratracheal, pretracheal, and subcarinal lymph node biopsies. Paraaortic and subaortic regions might be explored by anterior mediastinotomy (ADM) or the Chamberlain procedure [10]. The procedure of choice for exploring adenopathies of the anterior mediastinum is the ADM, which, when combined with SCM, provides complete assessment of the lymph node groups. It was also noticed that tumors in the anterior mediastinum could be sampled using ADM [10]. Watanabe and associates [3] reported that diagnostic accuracy was significantly higher in mediastinotomy biopsies than in needle biopsies. However, mediastinotomy biopsy is a considerably invasive procedure because of routine costal resection, localization and length of incision, necessity of overnight hospitalization, and probability of pleural opening.
Extended cervical mediastinoscopy has demonstrated its effectiveness in staging the subaortic and paraaortic node chains that are in other ways explored by anterior mediastinotomy or video-assisted thoracoscopy (VATS) [5–7, 11]. However, the diagnostic yield of VATS was reported to be 91.9% and was comparable to that of mediastinotomy and ECM [12]. We maintained the true diagnosis in 8 of 9 patients (ie, 89%). Extended cervical mediastinoscopy seemed to be advantageous with regard to hospitalization stay: The average duration of stay in the series of Landrenau and associates [12] (3 days) was higher than in our study. Moreover, in our study, 8 of 9 patients were discharged home on the same day of operation with a mean hospitalization time of 8 hours.
Additionally, specific complications of VATS such as vascular injuries or postoperative respiratory problems do exist [13], whereas these side effects have not been reported after ECM. In our series, only one minimal pneumothorax not requiring thoracostomy occurred. Video-assisted thoracoscopy also requires three thoracic incisions, double lumen intubation to produce pulmonary collapse, and chest tube insertion. In VATS, the presence of tight pleural adhesions is recognized as a cause of failure.
Extended cervical mediastinoscopy was also described as a tool to access the superior mediastinum, namely, the substernal prevascular plane, which is not entered during SCM [5]. In fact, in our series, four of nine lesions had extensions to the superior mediastinum. However, in all of the patients, the histologic diagnosis made from the ECM biopsy was obtained from the anterior mediastinum.
This report demonstrated that ECM can be a safe and effective diagnostic tool for anterior mediastinal masses in patients with inconclusive TNB and Tru-cut biopsy results. However, the efficacy of extended mediastinoscopy in the diagnosis of anterior mediastinal masses awaits confirmation by larger or randomized clinical trials.
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References
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Abstract
Introduction
