Showing papers on "Mediastinoscopy published in 1999"

Cost-efficacy of endoscopic ultrasonography with fine-needle aspiration vs. mediastinotomy in patients with lung cancer and suspected mediastinal adenopathy.

Abstract: Background and Study Aims: The use of endoscopic ultrasonography (EUS) guidance for fine-needle aspiration (FNA) of mediastinal lymph nodes has become an important aid in the staging of bronchogenic carcinoma. In many cases, it may be an alternative to mediastinoscopy/mediastinotomy (MED), but the cost-effectiveness of the two techniques has not been compared. The aim of this study was to apply a decision-analysis model to compare the cost-effectiveness of EUS and MED in the preoperative staging of patients with non-small-cell lung cancer. Patients and Methods: A decision-analysis model was designed, taking as entry criteria lung cancer and abnormal mediastinal lymph nodes verified by computerized tomography (CT). Performance characteristics of MED and EUS were retrieved from the published literature, as were life expectancy data. Direct actual costs of the relevant procedures were retrieved from the billing system of our hospital. Results: The cost per year of expected survival is US$ 1.729 with the EUS strategy, and US$ 2.411 with the MED strategy. The advantage conferred by EUS remains even when the negative predictive value of EUS is as low as 0.22. Conclusion: Because of its low cost and high yield, EUS-guided FNA is a cost-effective aid assessing mediastinal lymphadenopathy.

Core needle biopsy is effective in the initial diagnosis of mediastinal lymphoma.

Abstract: BACKGROUND AND OBJECTIVE: With the development and refinement of guidance modalities for percutaneous biopsies, many investigators have reported studies supporting the role of guided core needle biopsy in the diagnosis of mediastinal lymphoma. The aims of this report are to evaluate the efficacy of findings at core needle biopsy of mediastinal masses on patient care and define the key determinants of clinical success. DESIGN AND METHODS: Fluoroscopy-guided (in 75 patients) and computed tomography-guided (in 8 patients) core needle biopsies were performed in 83 patients with mediastinal lymphoma: all but one of the patients were at first diagnosis. All the biopsies were performed using a Menghini needle (from 1.2 mm to 1.8 mm). In the vast majority of cases the 1.8 mm gauge was employed. RESULTS: The overall sensitivity for the diagnosis of lymphoma was 81% (67/83 cases). In the remaining 16 patients the lymphoma diagnosis was reached either by mediastinoscopy (11 cases) or anterior mediastinotomy (3 cases) or core needle biopsy of the lung (1 case); one patient was treated directly after the needle biopsy had been unsuccessful because he needed rapid therapy. In 77/82 (93%) patients it was possible to assess the specific histotype. There was no operative mortality; all the biopsies were performed on an outpatient basis. INTERPRETATION AND CONCLUSIONS: Our data indicate that core needle biopsy should be considered as an effective and safe procedure in the diagnosis of patients with mediastinal lymphoma with the possibility of determining the tumor subtype and subsequent specific treatment.

F-18 fluorodeoxyglucose positron emission tomography in the non-invasive staging of non-small cell lung cancer.

Abstract: Objective: Positron emission tomography (PET) using F-18 fluorodeoxyglucose (FDG), a glucose analogue, as a metabolic tumour marker, has been proposed for the non-invasive staging of oncological disease. Tumours demonstrate increased glycolytic activity and thereby, FDG PET can differentiate benign from malignant lesions. To determine its role in the mediastinal staging of patients with suspected non-small cell lung cancer, a prospective study of FDG PET and computed tomography (CT) compared to surgery and pathology was performed. The analysis group consists of 50 patients, 37 men and 13 women, mean age 64 years (range, 41‐78 years). Methods: A nuclear physician, blind to the clinical and CT data, graded the FDG PET studies qualitatively on a five-point scale, based on the intensity of glucose uptake, for the presence of mediastinal nodal tumour involvement. Scores of four or greater were considered positive for tumour. An experienced radiologist interpreted the patients’ CT scans blind to the other data. The CT criterion for tumour involvement was a nodal long axis diameter of 10 mm or greater. All patients underwent either thoracotomy or mediastinoscopy to obtain surgical specimens. The PET, CT, surgery and pathology were mapped according to the American Thoracic Society nodal classification resulting in 201 nodal stations evaluated. The imaging studies were analysed for N2 or N3 tumour involvement compared to histology or dissection of nodal stations. Results: All patients had proven non-small cell lung carcinoma. PET excluded tumour in 175 of 181 nodal stations (specificity 97%) compared to 162 of 181 (specificity 90%) by CT. PET correctly identified 16 of 20 (sensitivity 80%) nodal stations with tumour compared to 13 of 20 by CT (sensitivity 65%). Overall, PET correctly staged 191 of 201 nodal stations (accuracy 95%) compared to 175 of 201 by CT (accuracy 87%). By the McNemar test, PET was significantly more specific than CT in excluding nodal tumour involvement (x 2 a 5:5; P , 0:05U: Conclusions: FDG PET is more specific than computed tomography in the non-invasive mediastinal staging of non-small cell lung cancer and has an important clinical role in the pre-operative staging of lung cancer patients. q 1999 Elsevier Science B.V. All rights reserved.

Radiologic staging of lung cancer.

Abstract: Preoperative tumor staging in patients with known or suspected non-small cell lung cancer is generally performed using contrast enhanced chest computed tomography (CT) (including the adrenal glands). Abdominal CT is generally unnecessary, given the low frequency of isolated liver metastases. The role of MRI is limited, and it is used mainly as a problem solving tool in certain specific situations. A CT showing no mediastinal lymph node enlargement usually oviates preoperative mediastinal lymph node sampling, with certain exceptions. If enlarged mediastinal lymph nodes are demonstrated at CT, then CT may be used to direct preoperative lymph node sampling via transbronchoscopic Wang needle biopsy, mediastinoscopy, mediastinotomy, or video assisted thoracoscopy.

Improvement of non-small-cell lung cancer staging by means of positron emission tomography.

Abstract: BACKGROUND Exact staging of ipsi- and contralateral mediastinal lymph-node metastases (N 1/2 vs. N3) is essential for the therapeutic strategy in non-small-cell lung cancer (NSCLC). CT and mediastinoscopy are the standards of reference for N staging. However, even with these combined measures the extent of invasion of mediastinal lymph nodes can remain vague. 18FDG Positron Emission Tomography (18FDG-PET) has recently been shown to detect invaded nodes with high accuracy. The purpose of this study was to evaluate 18FDG-PET as an aid in N staging. METHODS 27 patients with suspected NSCLC were clinically staged by means of CT, bronchoscopy, mediastinoscopy, and bone scintigraphy. Additionally, 18FDG-PET was performed preoperatively for analysis of topography of invaded lymph nodes. CT and 18FDG-PET were evaluated in a blinded fashion. Surgical therapy was performed with radical lymphadenectomy. CT N staging as well as PET N staging results were compared with the pathological diagnoses (pTN). Specificity, sensitivity, and accuracy of CT and PET in N staging were calculated. RESULTS 14 squamous-cell carcinomas, 10 adenocarcinomas, and 3 non-malignant tumors were found. In 8 patients no invasion was found (N0), in 13 patients an ipsilateral invasion (N1/2), and in 3 patients a contralateral invasion (N3). In the correct detection of N1/2 the sensitivity of CT and of PET was 0.77, the specificity of CT and of PET was 0.79. The accuracy of CT was 0.74 and of PET 0.78. By combining CT and PET accuracy was 0.85. CONCLUSIONS Adequate preoperative LN staging is possible with both CT and 18FDG-PET. The accuracy, however, can be improved by a combination of CT and 18FDG-PET.

FDG-PET in the Locoregional Lymph Node Staging of Non-small Cell Lung Cancer. A Comprehensive Review of the Leuven Lung Cancer Group Experience.

Abstract: Exact staging of locoregional lymph node (LN) disease in non-small cell lung cancer (NSCLC) is of considerable clinical interest. Computed tomography (CT) is not very accurate for this purpose. In the past years, we performed several prospective studies examining the role of [18F]fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET) in this setting. We compared the accuracy of CT, PET, and PET read with the anatomical aid of CT images in the distinction of early-stage operable cases (i.e., without metastatic LN or with only hilar metastatic LN) versus locally advanced cases (with metastatic mediastinal LN). LNs on PET were recorded as metastatic if the FDG-uptake was more intense than the mediastinal blood pool activity. In 105 patients (or an analysis of 980 LN stations), the accuracy of PET (85%) was significantly better than that of CT (64%; P = 0.0003). Visual correlation with CT images further improved the results to an accuracy of 90%. We also examined the value of different acquisition protocols and interpretation algorithms. The use of Standardized Uptake Values (SUVs) of LNs, or of anatometabolic PET-CT-fusion images, did not prove to be of additional value compared to visual PET-reading and correlation with the CT images. On the condition that positive-LN findings on PET are always confirmed by mediastinoscopy, a simple whole-body acquisition protocol is adequate. We conclude that FDG-PET plays an important role in LN-staging in NSCLC. The very high negative predictive value of mediastinal FDG-PET is able to reduce the need for invasive surgical staging substantially.

Result of induction chemotherapy followed by surgery in patients with stage IIIA N2 NSCLC: importance of pre-treatment mediastinoscopy.

Abstract: Objective: Data from the literature indicate that chemotherapy prior to resection may improve the results. However, only few and conflicting data are reported regarding the correlation between downstaging of mediastinal nodes and outcome. The aim of this study was to look at the correlation between downstaging, survival and pre-treatment staging. Material and methods: Between March 1995 and August 1998, 46 consecutive patients with pathology proven N2 disease were treated with three cycles of vindesine-ifosfamide-platinum (VIP). All patients underwent a rigorously performed cervical mediastinoscopy. Patients with at least partial response (na 26) were surgically explored. Results: The clinical response rate to chemotherapy was 57% (26 patients). Resection was complete in 23 patients (88.5%). Pneumonectomy was performed in 16 patients. In 11 patients (42.9%) the mediastinal nodes (which were positive at mediastinoscopy) had become negative (downstaging group). The projected 2-year survival of resected patients is 41%. Patients with downstaging of nodes had no better survival compared to patients with no downstaging. Patients with involved subcarinal nodes at mediastinoscopy and patients with involvement of more than one level had a worse survival. Conclusion: Surgery in N2-patients responsive to induction chemotherapy resulted in a high complete resectability rate. Findings at pre-treatment mediastinoscopy proved to be the most important prognostic factor. q 1999 Elsevier Science B.V. All rights reserved.

Extended resections for lung cancer. How far is too far

Abstract: Pulmonary resection is the preferred treatment for patients with lung cancer. Half of all patients, however, have signs of unresectability at the time of diagnosis. Contraindication to pulmonary resection is based on cell type, the extent of the disease, and the patient's overall general medical condition. Invasion of the chest wall by bronchogenic carcinoma is not rare. The diagnostic importance of this findings, however, has been controversial. Early reports had regarded thoracic wall invasion as a uniformly ominous sign, while recent reports have been more optimistic, especially when lymph nodes were not metastatically involved. Chest wall resection should be preceeded by mediastinoscopy. If lymph nodes are negative, excision is generally performed en bloc with pulmonary resection. After the thorax is entered and the cancer is found to be invading the chest wall, wide resection of the chest wall with attached lung is performed. Generally, the line of resection should encompass the area of invasion by several centimeters. The lung with attached chest wall is then allowed to fall back into the pleural cavity, where the appropriate pulmonary resection is performed. If the chest wall defect is less than 5 cm in diameter, no reconstruction of the defect is required. If, however the defect is larger and structural, stability is required. The defect should be reconstructed with a prosthetic material, such as the various meshes, metals, or soft tissue patches, and reinforced with a muscle flap. If the wound is contaminated from an intrathoracic source, prosthetic material should be avoided and reconstruction with a muscle flap alone is preferred. Muscles commonly used include serratus anterior, pectoralis major, latissimus dorsi, and occasionaly, rectus abdominus. Because the omentum lacks structural stabilitly, it should be considered a back-up alternative procedure. Operative mortality is usually related to the extent of pulmonary resection rather than the extent of chest wall resection. Five-year survival approaches 50% for patients with T3N0M0 lesions. For patients with either N1 or N2 neoplasms, 5-year survial is less than 10%. Postoperative radiation therapy appears to have no effect on surival.

Staging of lymph nodes with FDG dual-headed PET in patients with non-small-cell lung cancer.

Abstract: Accurate assessment of mediastinal lymph node involvement in patients with non-small-cell lung cancer (NSCLC) is necessary to select patients for direct surgical treatment. The aims of the present study were to assess the feasibility of staging NSCLC with FDG using a dual-headed positron emission tomographic (PET) camera and to compare this non-invasive technique with computed tomography (CT) and lymph node sampling, since both modalities are currently used for staging NSCLC. Thirty-three patients (29 men and 4 women, mean age 60 years) with newly diagnosed NSCLC were studied. In all patients, CT, FDG dual-headed PET and mediastinoscopy were performed within 4 weeks. The results of mediastinoscopy were used to select patients for thoracotomy. For both the assessment of individual lymph node involvement and the patient-based classification, the results of FDG dual-headed PET and CT were compared using the McNemar test. Thirty-one of 187 lymph nodes studied contained tumour metastases. FDG dual-headed PET showed a significantly higher sensitivity (P < 0.001) and specificity (P < 0.001) than CT. FDG dual-headed PET and CT correctly staged 27 and 20 patients, respectively. Due to the significantly higher negative predictive value of FDG dual-headed PET versus CT (P = 0.012), it was a better non-invasive diagnostic tool for selecting patients for surgery. In seven of eight patients, additional intrapulmonary sites of increased uptake were found, which revealed malignancy on histological examination. CT was false-negative in three of these patients. In one patients, increased FDG uptake was caused by an infection. In conclusion, it is possible to stage mediastinal lymph nodes in patients with NSCLC using a dual-headed PET camera. The high negative predictive value of FDG dual-headed PET suggests that mediastinoscopy may be omitted in patients with NSCLC.

[Value of Pet-18FDG in lung cancer].

Abstract: INTRODUCTION: 18FDG-PET was studied in the diagnosis of malignancy of the solitary pulmonary nodule and in the early staging of non-small-cell lung cancer. PET results were compared with thoracic-abdominal computed tomography (CT) and brain magnetic resonance (MR). PATIENTS AND METHODS: Fifty-five patients with a radiologically detected solitary pulmonary nodule (54 CT, 1 plain radiography), were studied following an intravenous injection of 370 MBq 18FDG. Attenuation corrected emission data were acquired and analyzed qualitatively and semi-quantitatively. 30 non-small-cell lung cancer underwent MR. Biopsies were obtained in 48 non-small-cell lung cancer and 7 were controlled by follow-up (18 months). The staging of 43 non-small-cell lung cancer was confirmed by surgery (n = 13), mediastinoscopy (n = 9) and follow-up (n = 21). RESULTS: PET correctly diagnosed 52 solitary pulmonary nodules with 3 false positives (100% sensitivity and 75% specificity). In the mediastinal staging (N), CT and PET demonstrated a sensitivity and specificity of 46% vs. 100%, and 59.3% vs. 93.3%, respectively. In 6 patients, some visceral metastases detected by PET were not detected by CT (including 3 adrenals), whereas 2 brain metastases in MR were not diagnosed by PET. PET was considered decisive in the treatment and follow-up of 17 patients (32.7%). CONCLUSIONS: Whole body PET imaging is a cost-effective diagnostic technique that simplifies the malignant characterization of solitary pulmonary nodule and improves the early staging of non-small-cell lung cancer. In combination with CT, PET makes an outstanding contribution to the correct assessment of therapeutical decisions in these patients.

The role of thoracic surgery in diagnosing interstitial lung disease.

Abstract: 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.

Clinical value of cervical mediastinoscopy in the staging of bronchial carcinoma.

Abstract: Whether mediastinoscopy is indicated in the preoperative staging of bronchogenic carcinoma is still a controversial issue. It may be performed routinely (to exclude locally inoperable patients from surgery), selectively, or it may be regarded as superfluous (in centers which prefer an extended lympho adenectomy at the time of thoracotomy). We regard mediastinoscopy as indicated for the following purposes: 1) staging of NSCLC and SCLC; 2) diagnostic (mediastinal masses or lung tumors without previous histology); 3) restaging after primary chemotherapy; 4) assessment of prognosis in patients with borderline operability. The indication for 224 mediastinoscopies performed at our institution in the period from September 1991 through March 1999 was mainly for staging (59.2%) or diagnostic (30.6%). Eight (5.4%) patients underwent mediastinoscopy for the assessment of operability, and 7 (4.8%) after primary chemotherapy for the restaging of loco-regionally advanced lung cancer. Sensitivity and specificity rates were 87% and 100%, respectively, with an accuracy of 93% for the mediastinoscopy performed for the staging of lung cancer at all stages. If we consider the N2 tumors (42 cases) alone, the sensitivity was 76.7% and the specificity 100%, with an accuracy of 83.3%. Overall positive and negative predictive value resulted 100% and 87%, respectively, according to the data reported in literature. Our data confirm the role of mediastinoscopy as the gold standard for regional staging of lung cancer.

Trimodality therapy in stage III non-small cell lung cancer: prediction of recurrence by assessment of p185neu

Abstract: In a trimodality treatment approach for stage III non-small cell lung cancer the prognostic impact of pretherapeutic p185neu assessment was evaluated. Fifty-four patients were admitted to chemotherapy followed by twice-daily radiation with concomittant low-dose chemotherapy and subsequent surgery. Immunohistochemical assessment of p185neu expression was performed in paraffin-embedded mediastinal lymph node metastases, by mediastinoscopy biopsy prior to therapy. Paraffin-embedded biopsies of mediastinal lymph node metastases were available in 33 cases. Seven out of eight patients with positive p185neu staining developed distant metastases, in contrast to seven out of 25 negative cases. Expression of p185neu in mediastinal lymph node metastases was a significant predictor for progression-free survival (p=0.047) and resulted mainly from significant differences in metastases-free survival (p185neu-positive versus p185neu-negative: median, 11 versus 19 months; 2- and 3-yr rates, 13% and 0% versus 40% and 32%; p=0.04). On the basis of these preliminary results it was concluded that further evaluation of p185neu expression in trials on neoadjuvant and adjuvant therapy is warranted. When the prognostic impact of p185neu in such trials with larger patient numbers is confirmed, this may contribute to the identification of stratification variables for future treatment approaches of non-small cell lung cancer.

Transbronchial needle aspiration (TBNA) in patients infected with HIV

Abstract: Transbronchial needle aspiration (TBNA) of intrathoracic lymph nodes has been shown to be useful in the diagnosis and staging of bronchogenic carcinoma. With the exception of sarcoidosis, the usefulness of TBNA has not been widely investigated in other clinical settings. We investigated the utility of TBNA with a 19-gauge histology needle in HIV-infected patients with mediastinal and hilar adenopathy at Bellevue Hospital Center. We performed 44 procedures in 41 patients. Adequate lymph node sampling was obtained in 35 of 44 (80%), and diagnostic material was obtained in 23 of 44 (52%) procedures. TBNA was the exclusive means of diagnosis in 13 of 41 (32%) patients. Of the 44 procedures, 23 (52%) were performed in patients with mycobacterial disease, with TBNA providing the diagnosis in 20 of 23 (87%). In these patients, positive TBNA specimens included smears of aspirated materials for acid-fast bacilli in 11, mycobacterial culture in 14, and histology in 15. In other diseases, TBNA diagnosed sarcoidosis with noncaseating granulomata in 2 of 4 patients and non-small cell lung cancer in 1 of 2 patients. TBNA was not helpful in other diseases including Pneumocystis carinii pneumonia, infection with Cryptococcus or Nocardia, bacterial pneumonia, viral pneumonia, and Kaposi's sarcoma. No pulmonary diagnosis was established in five patients. No complications of TBNA occurred. We conclude that TBNA through the flexible bronchoscope is safe and effective in the diagnosis of intrathoracic adenopathy in HIV-infected patients, and is particularly efficacious in the diagnosis of mycobacterial disease. Furthermore, TBNA may provide the only diagnostic specimen in almost one-third of HIV-infected patients, thereby sparing these patients more invasive procedures such as mediastinoscopy.

Role of video-assisted thoracic surgery (VATS) in staging, diagnosis and treatment of lung cancer.

Abstract: VATS, video-assisted thoracic surgery, is presently used for a variety of thoracic disorders and represents a new approach to thoracic disease. It plays a specific role in staging, diagnosis and treatment of lung cancer. For precise mediastinal lymph node staging, cervical mediastinoscopy remains the gold standard. VATS can replace anterior mediastinoscopy and is useful to take biopsies of lymph nodes not accessible by cervical mediastinoscopy and to judge resectability of the primary tumour. Precise diagnosis of solitary pulmonary nodules is possible by VATS but protective measures should be taken to prevent spillage of tumour cells. Positron emission tomography has recently proven to be valuable in staging and diagnosis of lung cancer but its precise role remains to be determined. VATS is presently not advocated for definite treatment of lung cancer. The only possible exceptions are peripheral T1N0 squamous cell carcinomas smaller than 2 cm., but resections less than lobectomy are oncologically not adequate.

Complicaciones técnicas de la exploración quirúrgica del mediastino en la estadificación del cáncer de pulmón

Abstract: Between January 1974 and December 1996 we performed exploratory surgery (mediastinoscopies/mediastinotomies) on 1,618 patients diagnosed of bronchogenic carcinoma who were considered functionally operable and whose cancer was believed to be resectable. Findings were positive in 26%. Thirty-four (2.1%) complications were encountered, with a significantly higher incidence of complication among those for whom the results of exploratory surgery were positive (p = 0.004) as follows: only 13 cases (0.8%) of significant bleeding; 12 cases (0.74%) of recurrent left nerve palsy (0.74%), 4 (0.25%) subcutaneous wound infections; 3 cases (0.18%) of pneumothorax; 1 (0.06%) perforated esophagus; and 1 case (0.06%) of chylomediastinum. The rate of morbidity associated with exploratory surgery was within the range reported in the literature. No deaths occurred. Mediastinoscopy, in our experience, is the most effective way of staging mediastinal ganglia. Provided the procedure is performed carefully by experienced surgeons, the risk of complication is minimal.

[Pulmonary nodule. The surgeon's approach].

Abstract: Malignancy must be suspected with any pulmonary nodule detected on radiologic examination of the chest until its benign origin has been proven. This requires further evaluation of the patient. The non invasive diagnostic steps include patient's history, clinical examination, lung function testing, and standard radiographs and a computed tomography (CT) of the chest. Based on these findings the presumed diagnosis claims the next appropriate diagnostic steps. If lung cancer is the most likely diagnosis and lung function testing revealed that the patient is a candidate for lung resection than surgery may be the next step. Preoperative proof of the histologic diagnosis is not mandatory. It is the less required the more surgery may be curative. If curative resectability is indoubt or the patient is not candidate for lung resection than histologic diagnosis should be confirmed prior to introduction of radiotherapy or chemotherapy by the least invasive procedure (bronchoscopy < lymph node biopsy < needle biopsy < mediastinoscopy/-tomy < VATS). If metastatic disease must be suspected, staging should be completed as required for the primary malignancy. With local recurrence and other metastases excluded the number of pulmonary nodules detected on CT scan points to the appropriate surgical approach. In case of a solitary nodule or multiple but resectable nodules, complete (wedge) resection with lymph node dissection through a lateral thoracotomy will be the procedure of choice. With multiple and unresectable nodules, surgery allows definitive diagnosis and videothoracoscopy affords the opportunity to accomplish wedge resection of the lung along with low morbidity. When lesions are deemed indeterminate, definitive diagnosis should nevertheless be attempted. If there is no history of malignancy routine evaluation for such in asymptomatic patients is not indicated. With small nodules (less than 3 cm in diameter) located in the periphery of the lung, videothoracoscopic wedge resection is indicated without preoperative sputum cytology, bronchoscopy or transthoracic needle biopsy. The histologic diagnosis obtained by intraoperative frozen sections than determines the further surgical approach. Benign lesion: completion of surgery; lung cancer: proceed to thoracotomy with anatomic lung resection and mediastinal lymph node resection; metastatic disease: completion of surgery and further search for primary malignancy.

Does percutaneous fine-needle aspiration biopsy aid in the diagnosis and surgical management of lung masses?

Abstract: OBJECTIVES To evaluate the ability of percutaneous, transthoracic fine-needle aspiration biopsy (FNAB) to correctly diagnose intrathoracic masses, to determine what complications were experienced and at what rate they occurred and to define more clearly the role of this technique in the surgical management of lung masses DESIGN A chart review SETTING Kingston General Hospital, Kingston, Ont, a tertiary care centre and university-affiliated teaching hospital PATIENTS One hundred and thirteen patients who underwent 117 percutaneous transthoracic FNABs between Jan 1, 1991, and July 1, 1996 OUTCOME MEASURES Patient demographics, size and location of the lesion, diagnostic result of FNAB, complications of the procedure, smoking history, number of needle passes made by the radiologist and results of any other available biopsy (ie, through bronchoscopy, mediastinoscopy, pleuroscopy) and of surgical resection, as well clinical information pertaining to the disease state in patients with nondiagnostic or negative FNAB RESULTS Eighty-six masses (735%) were diagnosed as malignant, 31 biopsy specimens (265%) were either nondiagnostic or negative for malignancy Of these specimens, 15 (484%) were subsequently shown to be cancer In 64 biopsies (547%), the patient suffered pneumothorax, requiring hospitalization and chest tube insertion in 35 (299%) and 24 (205%) cases respectively The size of the lesion was related to both the diagnostic accuracy and the incidence of pneumothorax CONCLUSIONS Percutaneous transthoracic FNAB should not be used routinely in the assessment of patients with lung masses who are medically fit to withstand surgery and are free of widespread disease The results of FNAB do little to modify the course of surgical management in these patients

[Mediastinal and hilar lymph node of cancer unknown origin: 3 case reports].

Abstract: We encountered three rare cases of cancer of unknown origin affecting the mediastinal and hilar lymph nodes. Patient 1 was a 63 year-old man. Chest X-ray and CT films revealed an enlarged right hilar lymph node. A right mediastinal and hilar lymphadenectomy was performed. The histological diagnosis was metastatic squamous cell carcinoma (SCC). SCC of the right upper lobe appeared 34 months after the operation, requiring a right pneumonectomy. Patient 1 was alive 43 months after his first operation. Patient 2 was a 73 year-old man in whom left mediastinal and hilar lymph node swelling had been detected. A mediastinoscopy and lymph node biopsy were performed. The histological findings resulted in a diagnosis of metastatic small cell carcinoma. Chemotherapy was initiated, and the patient was alive 5 months after the biopsy procedure, Patient 3 was a 57 year-old man in whom right mediastinal and hilar lymph node swelling had been disclosed by chest CT scans. We performed a medianosternotomy and mediastinal and right hilar lymphadenectomy. Histologically, the diagnosis was metastatic adenocarcinoma. After the operation, radiation therapy was performed on the patient's mediastinum. Patient 3 was alive 5 months after the initial operation. The patients were given diagnoses of T0N1 or T0N2 lung cancer.

Surgical staging of lung cancer.

Abstract: The staging of lung cancer defines the extent of disease. Accurate staging is important to define operability, select treatment regimens, and predict survival. Nonsurgical and surgical techniques are used to stage patients. The most important nonsurgical techniques used currently are the chest x-ray and computed tomographic (CT) scan of the chest and upper abdomen. In the future, positron emission tomography (PET) may become the single most important nonsurgical investigation. Surgical staging involves histologic assessment of the primary tumor and potential sites of metastases. At present, the standard for surgical staging is cervical mediastinotomy. Other minimally invasive surgical procedures used to stage patients with lung cancer are scalene lymph node biopsy, bronchoscopy with transbronchial biopsy, anterior mediastinoscopy, and video-assisted thoracoscopy. The different surgical staging options and their indications will be discussed in depth.

Surgical exploration of the mediastinum by mediastinoscopy, parasternal mediastinotomy and remediastinoscopy: indications, technique and complications.

Abstract: Imaging diagnostics often fail to provide enough certainly to make therapeutic decisions, since radiological images do not always correlate well with the pathological condition of the lesions Surgical exploration of the mediastinum by mediastinoscopy allows to obtain very accurate information from inspection, palpation and biopsies of lymph nodes or tumors directly affecting the mediastinum Mediastinoscopy assesses the upper mediastinum, including nodal stations 1, 2R, 2L, 3, 4L, 7, 10R and 10L It can also assess direct invasion of the mediastinum from adjacent tumors Parasternal mediastinoscopy is a complementary technique to reach nodal stations 5 and 6, which cannot be reached with standard cervical mediastinoscopy Remediastinoscopy has been performed to restage tumors after delayed treatment and to stage second primary and recurrent tumors It has proved useful, too, to restage N2 lung cancer after induction chemotherapy In all these indications, remediastinoscopy was technically possible All these techniques are associated with very few complications (around 3%) and a low mortality rate of less than 1%