Showing papers on "Mediastinoscopy published in 1993"

Radiation therapy alone for stage I non-small cell lung cancer

Abstract: Purpose: This paper is a retrospective analysis of patients with clinical Stage I non-small cell carcinoma of the lung treated with definitive radiation therapy alone. The results of therapy, patterns of failure and the relationship of technical aspects of the delivery of radiotherapy to outcome are presented. Materials and Methods: From 1980 through 1990, 53 patients with Stage I non-small cell lung cancer were treated with definitive radiation therapy alone at the Radiation Oncology Center of the Mallinckrodt Institute of Radiology and its affiliated hospitals. All patients had a pathologic diagnosis of non-small cell lung cancer and were not candidates for surgical resection because of either patient refusal (10 patients), poor performance status (5 patients), or premorbid medical problems (38 patients). The median age was 73 years. Histologic cell type included squamous (32), adenocarcinoma (11), large cell (4), and unclassified non-small cell (6). Initial tumor size was s 3 cm in 23 patients, between 3 and 5 cm in 13 patients and ≥ 5 cm in 17 patients. Diagnostic staging varied during the study period. All patients had chest X-rays and computed tomography scans of the chest. A majority had liver and bone scans, but only four underwent mediastinoscopy. The radiation therapy was of megavoltage energy in all patients, with a median primary prescription tumor dose of 63.2 Gy. Survival was measured from the date radiation therapy was initiated. Results: The actuarial overall survival rate for the entire group was 19% at 3 years and 6% at 5 years, with a median survival time of 20.9 months. Of the 49 deaths, 35 died of lung cancer; 13 died of intercurrent illness, and one died of pancreatic cancer, which made the actuarial cause-specific survival 33% at 3 years and 13% at 5 years. The actuarial 3-year disease-free survival was 33%. Local primary tumor progression occurred in 22 patients, resulting in a 51% 3-year actuarial freedom from local progression. An additional four patients failed in regional lymph nodes that were included in the original treatment portals. Multivariate analysis found only T stage to be associated with overall survival ( p = .02). However multivariate analysis showed age as a prognostic factor to be approaching statistical significance ( p = .07). Patients under 70 years of age showed an increased survival rate compared to patients over 70 years. Radiation therapy doses ≥ 65 Gy appeared to result in a decreased proportion of patients dying of lung cancer with no apparent increase in either acute or long-term complication rates. Conclusion: Results of definitive radiation therapy for inoperable Stage I non-small cell lung remain inferior to surgical therapy. Potential methods to improve local control with radiotherapy are discussed.

T1 lung cancer: prevalence of mediastinal nodal metastases and diagnostic accuracy of CT.

Abstract: To determine the prevalence of mediastinal lymph node metastases in T1 non-small cell lung cancer and assess the sensitivity and specificity of computed tomography (CT) in detection of such metastases, the CT scans and surgical findings in 104 patients with T1 lesions were reviewed. Nodes longer than 10 mm on the short or long axis were considered abnormal. All patients underwent thorough mediastinal lymph node dissection at mediastinoscopy or thoracotomy. A total of 362 lymph nodes were sampled. Nodal metastases were present in 22 patients (21%). The sensitivity of CT for metastases to individual nodal stations was 41% for nodes measured on the short axis and 55% for those measured on the long axis. The specificity was 93% and 86%, respectively. When the adjacent nodal stations were included in the analysis, the sensitivity of CT was 59% for nodes measured on the short axis and 77% for those measured on the long axis; the specificity was 91% and 73%, respectively. T1 lung cancer has a higher prevalence of lymph node metastasis than previously reported, and CT is recommended in the preoperative staging of this disease.

Importance of clinical staging in limited small-cell lung cancer: a valuable system to separate prognostic subgroups. The University of Toronto Lung Oncology Group.

Abstract: PURPOSEIn an attempt to assess the response to treatment and survival of a group of patients treated with standard chemotherapy and radiotherapy, we undertook a retrospective review of small-cell lung cancer (SCLC) patients treated by the University of Toronto Lung Oncology Group.PATIENTS AND METHODSWe reviewed the records of 264 patients with limited SCLC who were treated from 1976 to 1985. Based on radiologic review and physical examination, patients were assigned to three prognostic groups: group 1 (very limited SCLC), negative mediastinoscopy and/or no evidence of mediastinal nodes on radiologic review; group 2, x-ray evidence of mediastinal node involvement or a positive mediastinoscopy; group 3, supraclavicular adenopathy or x-ray evidence of pneumonic consolidation, pleural effusion, or atelectasis. All patients received combination chemotherapy, radiotherapy to the primary site, and prophylactic cranial irradiation.RESULTSComplete response was seen in 52% of patients and partial response in 29%. R...

Tumors in the mediastinum: US-guided histologic core-needle biopsy.

Abstract: PURPOSE: To assess the clinical utility of ultrasound (US)-guided core-needle biopsy (CNB) of the mediastinum performed with a one-hand automatic-sampling technique. MATERIALS AND METHODS: Diagnostic or pathologic findings of US-guided CNBs performed with 14- or 18-gauge needles in 62 biopsies of mediastinal lesions were reviewed. RESULTS: An average of 2.4 punctures were performed at each biopsy session. A specimen sufficient for diagnosis was obtained in 52 of 62 biopsies (84%). There were no serious complications. CONCLUSION: When a mediastinal tumor is visible at US, US-guided CNB of the mediastinum is an accurate and safe technique. The method is a simple and cost-effective alternative to more invasive techniques such as mediastinoscopy or open diagnostic surgery.

Screening, diagnosis, and staging of lung cancer.

Abstract: Lung cancer has now displaced coronary heart disease as the single leading cause of excess mortality among smokers in the United States. Because screening by chest radiography and sputum cytology did not result in a reduction in lung cancer mortality, current research is directed at identifying earlier markers of malignancy. Molecular genetic and immunohistochemical techniques may now be applied to sputum cytology, and it may be possible to use such tests to screen certain subpopulations who are at extremely high risk for the development of lung cancer. Computed tomography scanning remains the most sensitive imaging technique for the evaluation and staging of patients with both small cell and non-small cell lung cancer. Several prospective trials have now shown that the specificity and sensitivity of computed tomography in the assessment of mediastinal nodes are still too low to eliminate the need for mediastinoscopy. Patients should not be denied thoracotomy on the basis of enlarged lymph nodes detected by computed tomography scan alone, and histologic verification of tumor involvement is essential, especially for patients who have obstructive pneumonitis. For extrathoracic staging, the diagnostic sensitivity and specificity of computed tomography and ultrasound are similar for the detection of liver metastases, but computed tomography is a more sensitive tool for detecting extrahepatic abdominal metastases. Monoclonal antibody imaging techniques currently do not seem to be either sensitive or specific enough to replace any of the current staging procedures more commonly in use.

Sonographically guided laparoscopy and mediastinoscopy using miniature catheter-based transducers.

Abstract: Miniature ultrasound transducers (12.5 MHz) housed in 9 Fr catheters were passed through a laparoscope or mediastinoscope to image a variety of normal and abnormal structures within the peritoneal cavity and mediastinum in 20 patients. These transducers made it possible to visualize the gallbladder and bile ducts and evaluate for the presence of stones, to detect masses and provide guidance for their aspiration or biopsy, and to image the internal structures of the ovary and fallopian tube. In addition, these miniature transducers were used to locate such normal vital structures as blood vessels, thereby allowing the surgeon to decide on the best approach for dissection during mediastinoscopy. During conventional surgery, the surgeon or gynecologist can palpate an area of abnormality not directly visualized. However, during laparoscopy and mediastinoscopy direct palpation is not possible. Therefore, it is important to find another method to determine what structures lie beneath the visualized surface. These miniature ultrasound transducers appear to offer a means for making such determinations.

Role of mediastinoscopy in superior vena cava obstruction.

Abstract: Background The role of mediastinoscopy in superior vena cava obstruction (SVCO) is not clearly defined. The authors set out to examine the efficacy and safety of mediastinoscopy in SVCO. Methods They reviewed 14 patients referred to one surgical team over an 8-year period (1982-1990) who required mediastinoscopy to establish a histologic diagnosis after other less invasive procedures had not established the diagnosis. Results Of the 14 patients, 11 had lung cancer, 2 had lymphoma, and 1 had malignant thymoma. Definitive tissue diagnosis was obtained in 13 cases. Mediastinoscopy was unsuccessful in one of the cases because no pathologic tissue could be identified at the time of the procedure. Tissue diagnosis could only be obtained in this patient after mediastinotomy, and a lymphoma was found. There was one complication of mediastinoscopy; one patient had arterial bleeding from the innominate artery that required limited sternotomy to control the bleeding. Conclusions The authors believe that mediastinoscopy is a safe and effective technique for establishing a histologic diagnosis in SVCO when less invasive techniques have been unsuccessful. The use of blind radiation therapy cannot be justified on an emergency basis; failure to obtain a histologic diagnosis will result in up to 20% of patients receiving inappropriate radiation therapy, making subsequent tissue diagnosis very difficult.

Results of surgical resection of stage IIIa (N2) non small cell lung cancer, according to the site of the mediastinal metastases

Abstract: Out of a series of 1563 consecutive patients submitted to thoracotomy for lung cancer between 1980 and 1990, 278 patients underwent a resection for a non small cell lung cancer (NSCLC) with mediastinal node metastases (N2). Selection of cases for surgery was carried out using CT from 1983 and mediastinoscopy for the patients with mediastinal lymph nodes larger than 1.5 cm from 1985: all patients with positive mediastinoscopy were excluded from thoracotomy, but 10 cases underwent a resection after neoadjuvant radio-chemotherapy. The surgical procedures were pneumonectomy (106), lobectomy (146) and atypical resection (8) with ipsilateral mediastinal lymphadenectomy. Resection was complete in 236 patients (84.8%) and incomplete in 42 patients (15.2%). Postoperative mortality was 3.2%. Almost all patients received radiotherapy after surgery. Actuarial 5-year survival was 13.7% for the entire group and 18.5% for the patients who underwent curative resection; no patients survived 5 years after palliative resection (p < 0.05). There were no differences with regard to prognosis according to the histology of the tumors and to surgical procedures. A better prognosis is associated with: completeness of resection, involvement of only one level, low T classification. Five-year survival rate of patients with metastases only in upper mediastinum was 25%; on the contrary 5-year survival rate of patients with metastases in the lymph nodes of the lower mediastinum was only 8% (p < 0.05). In our opinion better results among the patients with metastases in the upper mediastinum depends on the selection obtained with mediastinoscopy.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic algorithm for acute superior vena caval obstruction (SVCO).

Abstract: Acute SVCO presents a serious diagnostic and therapeutic dilemma to the thoracic surgeon. It is highly desirable to obtain a definitive tissue diagnosis but this requirement must be balanced against the risks inherent in invasive diagnostic procedures in these oft-times critically ill patients. In the past 5 years we have developed an algorithm that has been used successfully in 18 patients presenting with acute SVCO. The decision tree consists of scalene node biopsy, bronchoscopy and mediastinoscopy with categorization into low and high risk groups in the latter. The gender distribution of the 18 patients was 12 male and 6 female with the ages being 58.3 +/- 16.3 and 64.2 +/- 11.2 years respectively. The duration of symptoms range from 1.5 to 12 weeks and averaged 4.5 +/- 3.2 weeks. Two patients had palpable scalene nodes which were positive at biopsy. Bronchoscopy was positive in 5 out of 11 examinations. In 5 instances it was not done. Twelve patients underwent various forms of mediastinal biopsy and one underwent sternotomy. Seven patients requiring mediastinoscopy were judged to be high risk as defined by severe airway and vascular obstruction. Perioperative difficulties occurred in two patients due to cardiorespiratory factors associated with the obstruction. Both patients were undergoing cervical mediastinoscopy under general anesthesia and no difficulties were encountered in high risk patients when local anesthesia was used to perform anterior mediastinotomy. Five patients that were considered low risk all underwent uncomplicated procedures under general anesthesia. Thirteen patients proved to have bronchogenic carcinoma and a specific tissue diagnosis was obtained in 12. The undetermined diagnosis was in a patient who had prior radiotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of Pancoast tumor.

Abstract: The treatment of superior pulmonary sulcus (Pancoast) tumor is not uniform and is still discussed. Literature data and our retrospective study are presented. Fourteen patients were operated for a Pancoast tumor. Nine patients underwent mediastinoscopy followed by preoperative radiotherapy. Five patients received adjuvant radiotherapy after incomplete resection. Five patients who did not have preoperative radiotherapy, received postoperative irradiation. All three patients who survived five years or more, had preoperative radiotherapy and two of them underwent a complete resection. Literature data are discussed and emphasis is laid on the importance of preoperative staging, including mediastinoscopy, preoperative radiotherapy and complete "en bloc" resection.

Chylomediastinum after mediastinoscopy. Apropos of a case

Abstract: A mediastinal chylous effusion occurred in a young woman after a mediastinoscopy. This effusion healed rapidly with medical treatment. An understanding of the anatomy of these intra-thoracic/lymphatic channels explains that intra-thoracic chylous effusions may occur in case of incontinence of the lymphatic vessels which connect the tracheo-bronchial nodes to the thoracic duct in the mediastinum. This is very important following the surgical excision of a node because incontinent lymphatic vessels are directly sectioned. When the lymph nodes are biopsied in an enclosed cavity such as the mediastinum, the quantity of lymphoid tissue acts as an obstacle to reflux of the lymph which is thus less significant and more easily controlled.

Laparoscopy/thoracoscopy for staging: II. Pretherapy nodal evaluation in carcinoma of the esophagus.

Abstract: Many surgical studies show a significant stratification of survival following resection of esophageal cancer based upon accurate pathologic staging. However, investigators are moving away from single modality therapy toward multimodality trials for the treatment of this disease. This presents a problem in staging of patients before therapy is begun. Chemotherapy and/or radiation therapy may alter the local tumor characteristics and nodal metastases, thus confounding evaluation of treatment results. Although CT scanning and transesophageal ultrasound help in assessing nodal status, they have not reached the precision necessary for study purposes. Pretherapy nodal staging using video-assisted exploration may provide the same level of accuracy as mediastinoscopy does for lung cancer.

Staging of bronchogenic carcinoma.

Abstract: Both computed tomography (CT) and magnetic resonance imaging (MRI) can provide important information not obtainable by chest radiography regarding staging of patients with bronchogenic carcinoma. However, while CT and MRI can both detect enlarged mediastinal nodes, this only approximately indicates tumor involvement. For example, enlarged nodes do not necessarily contain tumor, so biopsy is necessary before declaring the patient inoperable. As well, normal-sized nodes may contain tumor, and whether mediastinoscopy is required in such situations is controversial. Similarly, neither MRI nor CT is highly accurate in detecting mediastinal or chest-wall involvement, although certain specific features can occasionally be highly predictive of invasion.

Contribution of transcervical mediastinoscopy and anterior mediastinostomy to the diagnosis of mediastinal lymphomas

Abstract: UNLABELLED The aim of this study has been to assess the profitability of mediastinal explorations (transcervical mediastinoscopy and anterior mediastinostomy) in the diagnosis of mediastinal lymphomas within a short-stay surgery programme. Out of 129 mediastinal explorations conducted within a period of six years, 63 were programmed as short-stay surgery, 24 of which were due to mediastinal lymphomas. Fourteen patients were discharged from the hospital within the first twelve hours and ten patients, after 24 hours. RESULTS There were 11 cases of Hodgkin's lymphomas and 13 non-Hodgkin's lymphomas. No immediate complications were developed by the patients, with just two minor complications which did not delay hospital discharge. CONCLUSIONS Mediastinal explorations (transcervical mediastinoscospy and anterior mediastinostomy) can be planned as short-stay surgery without any risks if they are conducted by groups with experience in these surgical techniques and provided with an adequate care infrastructure. This allows a more rationale usage of hospital resources without reducing the quality of care.

Ultrasound-guided tumor biopsy in the anterior mediastinum. An alternative to thoracotomy and mediastinoscopy.

Abstract: REFERENCES I. EKSTEIN M. R., KELEMOURIDIS v; ATHANASOULIS C. A., WALTMAN A. C, FELDMAN L. & VAN BREDA A.: Gastric bleeding. Therapy with intra-arterial vasopressin and transcatheter embolization. Radiology 152 (1984), 643. 2. HEMINGWAY A. P. & ALLISON D. J.: Complications of embolization. Analysis of 410 procedures. Radiology 166 (1988), 669. 3. LOHELA P, SOIVA M., SURAMO 1., TAAVITSAINEN M. & HOLoPAINEN 0.: Ultrasonic guidance for percutaneous puncture and drainage in acute cholecystitis. Acta Radiol. 27 (1986), 543. 4. MCGAHAN J. P. & LINDFORS K. K.: Acute cholecystitis. Diagnostic accuracy of percutaneous aspiration of the gallbladder. Radiology 167 (1988), 667. 5. ONODERA H., OIKAWA M., ABE M. & GOTO Y.: Gallbladder necrosis after transcatheter hepatic arterial embolization. A technique to avoid this complication. Radiology 152 (1984), 209. 6. VANSONNENBERG E., D'AGOSTINO H. B., CASOLA G., VARNEMY R. R. & AINGE G. D.: Interventional radiology of the gallbladder. Diagnosis, drainage, dissolution, and management of stones. Radiology 174 (1990), I. 7. TEPLICK S. K., BRANDON J. C, WOLFERTH C C., AMRON G., GAMBESCIA R. & ZITOMER N.: Percutaneous interventional gallbladder procedures. Personal experience and literature review. Gastrointest. Radiol. 15 (1990), 133. 8. VOGELZANG R. L.: Percutaneous cholecystostomy. Indications, anatomic considerations and technique. In: SylJabus: A categorial course in interventional radiology, p. 91. Edited by P. R. Mueller et al. Radiol. Soc. North Am., Chicago 1991.

A case of eosinophilic pneumonia with histologically proven mediastinal lymph node involvement

Abstract: Intrathoracic lymphadenopathy in eosinophilic pneumonia is very rare and few cases have been confirmed histologically This is the first case of eosinophilic pneumonia with mediastinoscopic lymph node biopsy reported in Japan The case is a 42-year-old man who was admitted to our hospital complaining of cough, general fatigue and dyspnea of one month's duration Chest X-ray demonstrated bilateral hilar and mediastinal lymph node enlargement with interlobar pleural thickening and infiltrative shadows in right lower lung field Computed tomography revealed infiltrative shadows at right S4, S5, S8 and S9 and S10 segments and #2, #3, #5, #6 lymph node enlargement Biopsy of the lymph node via mediastinoscopy demonstrated that the architecture was preserved, sinusoids were filled with histiocytes and eosinophils, and lymphoid follicles were compressed Immunohistochemical technique using monoclonal antibody EG2 which reacts with the secreted form of Eosinophilic Cationic Protein (ECP), demonstrated that eosinophils infiltrating the mediastinal lymph nodes were activated The pathogenesis of mediastinal lymphadenopathy in eosinophilic pneumonia remains to be determined, but our case suggests that mediastinal lymph nodes may play a role in eosinophilic pneumonia

Primary surgical resection of tumors of the anterior mediastinum

Abstract: Seventy-two anterior mediastinal tumors were operated upon between 1981 and 1991. This accounted for 2% of the 3579 thoracotomies performed during the same period (excluding cardiac surgery). With the exception of Hodgkin's disease, lymphomas and metastases diagnosed either by anterior mediastinoscopy or at thoracotomy, other tumors were treated by the widest possible excision followed by adjuvant treatment in case of incomplete excision. These tumors included 16 metastatic carcinomas and 55 affecting the thymus-including 27 malignant thymomas and 15 benign tumors of the thymus including 2 carcinoids, 6 cases of Hodgkin's disease involving the thymus, 5 non-seminomatous germinal tumors, one differentiated neuro-endocrine carcinoma, 1 thymus lymphoma and 1 seminoma. The approach was via sternotomy in 32 cases and thoracotomy in the other 40. Excision was deemed complete in 45 cases, incomplete in 25 cases and impossible in 2 cases. Extension of surgical excision involved various adjacent organs: the lung in 10 cases and the pericardium in 5. Involvement of the phrenic nerves was found in 25 cases, the aorta in 1, the pulmonary artery in 1 and the vena cava or its afferent vessels in 33 cases. Seven PTFE venous bypasses were performed. Operative mortality was nil. One patient died on the 8th day of undefined causes. Mean tumour survival in metastatic thymomas was nevertheless 19 months. Survival in malignant thymomas was related to the stage of progression of the tumour. When complete excision was possible, survival was 89% with a mean follow-up of 57 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Ethanol sclerosis of a mediastinal cyst.

Abstract: The authors report a mediastinal cyst treated by aspiration and ethanol sclerosis, which were performed under ultrasonographic guidance. Mediastinoscopy and thoracotomy were thus avoided. One year later there had been no recurrence of the cyst or any symptoms.

[Diagnosis of mediastinal neoplasms using mediastinoscopy and CT-guided needle biopsy supported by gene analysis].

Abstract: Of 140 cases of mediastinal neoplasms in our hospital, histological diagnosis was confirmed in 129 cases. We examined the methods of preoperative biopsy with those 129 cases. Biopsy had been performed in 25 cases. Mediastinoscopy was performed in seven cases, needle biopsy in eight cases, lymph node biopsy in eight cases, esophageal biopsy using a gastrofiberscope in one case, transbronchial biopsy using a bronchoscope in one case. The true positive rates of those methods were 100% for both mediastinoscopy and lymph node biopsy, and 75% for needle biopsy. Preoperative misdiagnosis occurred in two cases of needle biopsy. The postoperative histological diagnosis was malignant lymphoma in both cases. We performed gene analysis of the immunoglobulin heavy chain gene, light chain kappa and lambda genes, and the T-cell receptor beta gene by use of biopsied specimens, and we found rearrangement bands of these genes in the cases of malignant lymphoma. Therefore, we summarize that gene analysis is a reliable method if malignant lymphoma is suspected. If a needle biopsy is performed under CT guidance, the needle is sure to puncture the tumor. We concluded, therefore, that if a tumor is located in the anterior mediastinum, CT-guided needle biopsy should be performed first of all. Mediastinoscopy is a useful method if the tumor is located in the mid-mediastinum.

How useful is mediastinoscopy today

Abstract: The present retrospective study evaluates 197 mediastinoscopies, performed between 1981 and 1990. The aim of the study was an actual evaluation of mediastinoscopy as an investigation for diagnosis and staging of intrathoracic diseases. Although the introduction of CT-scanning has caused a considerable decrease in the number of performed mediastinoscopies per year, we find that mediastinoscopy because of its high sensitivity (75%) and specificity (100%) still has an important place in the evaluation of intrathoracic diseases. It represents no alternative to CT, but a complementary diagnostic tool. As a conclusion four indications for mediastinoscopy today are proposed.

A surgical case of non-hodgkin lymphoma originating from the thymus

Abstract: A 65-year-old was admitted to the hospital because of dyspnea on exertion. There were previous histories of pulmonary tuberculosis, emphysema and right pneumothorax. Chest X-ray film showed an superior mediastinal tumor. Chest CT, MRI and Ga-scintigraphy showed the tumor originating from the thymus with metastasis to the superior mediastinal lymph nodes. It was difficult to perform transcutaneous needle biopsy and mediastinoscopy based on his radiologic studies. Therefore, surgical extirpation of the tumor was performed by median sternotomy for differential diagnosis. Although the tumor had invaded the right phrenic nerve, the surgery resulted in incomplete resection due to his reduced pulmonary function. The pathological diagnosis was non-Hodgkin lymphoma, diffuse and mixed type. Postoperatively, he received chemotherapy. For mediastinal malignant lymphoma, chemotherapy with or without radiation therapy is the treatment of choice. Surgical resection is rarely performed in the management of these patients. However, surgery should be performed for differential diagnosis, if biopsy is not feasible and the tumor is localized in the anterior mediastinum.