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Mediastinoscopy is a surgical procedure that allows physicians to view areas of the mediastinum, the cavity behind the breastbone that lies between the lungs. The organs in the mediastinum include the heart and its vessels, the lymph nodes, trachea, esophagus, and thymus.
Mediastinoscopy is most commonly used to detect or stage cancer. It is also ordered to detect infection, and to confirm diagnosis of certain conditions and diseases of the respiratory organs. The procedure involves insertion of an endotracheal (within the trachea) tube, followed by a small incision in the chest. A mediastinoscope is inserted through the incision. The purpose of this equipment is to allow the physician to directly see the organs inside the mediastinum, and to collect tissue samples for laboratory study.
Mediastinoscopy is often the diagnostic method of choice for detecting lymphoma, including Hodgkin's disease. The diagnosis of sarcoidosis (a chronic lung disease) and the staging of lung cancer can also be accomplished through mediastinoscopy. Lung cancer staging involves the placement of the cancer's progression into stages, or levels. These stages help a physician study cancer and provide consistent definition levels of cancer and corresponding treatments. The lymph nodes in the mediastinum are likely to show if lung cancer has spread beyond the lungs. Mediastinoscopy allows a physician to observe and extract a sample from the nodes for further study. Involvement of these lymph nodes indicates diagnosis and stages of lung cancer.
Mediastinoscopy may also be ordered to verify a diagnosis that was not clearly confirmed by other methods, such as certain radiographic and laboratory studies. Mediastinoscopy may also aid in certain surgical biopsies of nodes or cancerous tissue in the mediastinum. In fact, the surgeon may immediately perform a surgical procedure if a malignant tumor is confirmed while the patient is undergoing mediastinoscopy, thus combining the diagnostic exam and surgical procedure into one operation when possible.
Although still performed in 2001, advancements in computed tomography (CT) and magnetic resonance imaging (MRI) techniques, as well as the new developments in ultrasonography, have led to a decline in the use of mediastinoscopy. In addition, better results of fine-needle aspiration (drawing out fluid by suction) and core-needle biopsy (using a needle to obtain a small tissue sample) investigations, along with new techniques in thoracoscopy (examination of the thoracic cavity with a lighted instrument called a thoracoscope) offer additional options in examining mediastinal masses. Mediastinoscopy may be required, however, when these other methods cannot be used or when the results they provide are inconclusive.
Because mediastinoscopy is a surgical procedure, it should only be performed when the benefits of the exam's findings outweigh the risks of surgery and anesthesia. Patients who previously had mediastinoscopy should not receive it again if there is scarring present from the first exam.
Several other medical conditions, such as impaired cerebral circulation, obstruction or distortion of the upper airway, or thoracic aortic aneurysm (abnormal dilation of the thoracic aorta) may also preclude mediastinoscopy. Anatomic structures that can be compressed by the mediastinoscope may complicate these pre-existing medical conditions.
Mediastinoscopy is usually performed in a hospital under general anesthesia. An endotracheal tube is inserted first, after local anesthesia is applied to the throat. Once the patient is under general anesthesia, a small incision is made usually just below the neck or at the notch at the top of the breastbone. The surgeon may clear a path and feel the patient's lymph nodes first to evaluate any abnormalities within the nodes. Next, the physician will insert the mediastinoscope through the incision. The scope is a narrow, hollow tube with an attached light that allows the surgeon to see inside the area. The surgeon can insert tools through the hollow tube to help perform biopsies. A sample of tissue from the lymph nodes or a mass can be extracted and sent for study under a microscope or on to a laboratory for further testing.
In some cases, analysis of the tissue sample which shows malignancy will suggest the need for immediate surgery while the patient is already prepared and under anesthesia. In other cases, the surgeon will complete the visual study and tissue extraction and stitch the small incision closed. The patient will remain in the surgery recovery area until it is determined that the effects of anesthesia have lessened and it is safe for the patient to leave the area. The entire procedure should take about an hour, not counting preparation and recovery time. Studies have shown that mediastinoscopy is a safe, thorough, and cost-effective diagnostic tool with less risk than some other procedures.
Patients are asked to sign a consent form after having reviewed the risks of mediastinoscopy and known risks or reactions to anesthesia. The physician will normally instruct the patient to fast from midnight before the test until after the procedure is completed. A physician may also prescribe a sedative the night before the exam and before the procedure. Often a local anesthetic will be applied to the throat to prevent discomfort during placement of the endotracheal tube.
Following mediastinoscopy, patients will be carefully monitored to watch for changes in vital signs or indications of complications of the procedure or the anesthesia. A patient may have a sore throat from the endotracheal tube, temporary chest pain, and soreness or tenderness at the site of incision.
Complications from the actual mediastinoscopy procedure are relatively rare—the overall complication rate in various studies has been 1.3-3.0%. However, the following complications, in decreasing order of frequency, have been reported:
- pneumothorax (air in the pleural space)
- recurrent laryngeal nerve injury, causing hoarseness
- tumor implantation in the wound
- phrenic nerve injury (injury to a thoracic nerve)
- esophageal injury
- chylothorax (chyle—a milky lymphatic fluid—in the pleural space)
- air embolism (air bubble)
- transient hemiparesis (paralysis on one side of the body)
The usual risks associated with general anesthesia also apply to this procedure.
In the majority of procedures performed to diagnose cancer, a normal result involves evidence of small, smooth, normal-appearing lymph nodes and no abnormal tissue, growths, or signs of infection. In the case of lung cancer staging, results are related to the severity and progression of the cancer.
Abnormal findings may indicate lung cancer, tuberculosis, the spread of disease from one body part to another, sarcoidosis (a disease that causes nodules, usually affecting the lungs), lymphoma (abnormalities in the lymph tissues), and Hodgkin's disease.
Fischbach, Frances Talaska. A Manual of Laboratory and Diagnostic Tests. 6th ed. Philadelphia: Lippincott Williams and Wilkins, 2000.
Pagana, Kathleen Deska, and Timothy James Pagana. Mosby's Manual of Diagnostic and Laboratory Tests. St. Louis, MO: Mosby, 1998.
Deslauriers, Jean, and Jocelyn Gregoire. "Clinical and Surgical Staging of Non-Small Cell Lung Cancer." Chest, Supplement (April 2000): 96S-103S.
Tahara R. W., et al. "Is There a Role for Routine Mediastinoscopy in Patients With Peripheral T1 Lung Cancers?" American Journal of Surgery December 2000: 488-491.
Alliance for Lung Cancer Advocacy, Support, and Education. P.O. Box 849, Vancouver, WA 98666. (800) 298-2436. http://www.alcase.org.
American Cancer Society. 1599 Clifton Rd. NE, Atlanta, GA 30329. 800-ACS-2345 http://www.cancer.org.
American Lung Association. 1740 Broadway, New York, NY 10019-4374. 800-LUNG-USA (800-586-4872). http://www.lungusa.org.
Endotracheal — Placed within the trachea, also known as the windpipe.
Hodgkin's disease — A malignancy of lymphoid tissue found in the lymph nodes, spleen, liver, and bone marrow.
Lymph nodes — Small round structures located throughout the body; contain cells that fight infections.
Pleural space — Space between the layers of the pleura (membrane lining the lungs and thorax).
Sarcoidosis — A chronic disease characterized by nodules in the lungs, skin, lymph nodes and bones; however, any tissue or organ in the body may be affected.
Thymus — An unpaired organ in the mediastinal cavity that is important in the body's immune response.
examination of the mediastinum by means of an endoscope inserted through an anterior midline incision just above the thoracic inlet.
Endoscopic examination of the mediastinum through a suprasternal incision, usually for biopsy of paratracheal lymph nodes.
[mediastinum + G. skopeō, to view]
Exploration of the mediastinum through a suprasternal incision.
mediastinoscopyA procedure in which an endoscope is inserted into the mediastinum, and regional structures (lungs and lymph nodes) are visualised to evaluate and/or manage neoplasms or other lesions.
Widened mediastinum of unknown cause, staging of a known cancer, confirmation of TB or sarcoidosis, diagnosis of mediastinal fibrosis.
Cervical mediastinoscopy (for right paratrachial and subcarinal LNs); anterior mediastinoscopy (for left mediastinum, especially in presence of left upper lobe lesions); anterior mediastinotomy (on either side).
< 3%; haemorrhage, pneumothorax, vocal cord paralysis, oesophageal perforation.
mediastinoscopySurgery A procedure in which an endoscope is inserted in the mediastinum, and regional structures—lungs and lymph nodes are visualized to detect neoplasms or other lesions needing evaluation or therapy; mediastinoscopy may be part of a 'staging procedure', where a Pt has a known malignancy, and metastases are identified to determine further management Indications Widened mediastinum of unknown cause, cancer staging, confirmation of TB or sarcoidosis, diagnosis of mediastinal fibrosis Types Cervical mediastinoscopy–for right paratrachial and subcarinal LNs; anterior mediastinoscopy–for left mediastinum, especially in presence of left upper lobe lesions; anterior mediastinotomy–on either side Complications < 3%; hemorrhage, pneumothorax, vocal cord paralysis, esophageal perforation. See Endoscopy, Mediastinotomy, Thoracotomy.
Exploration of the mediastinum through a suprasternal incision, for biopsy of paratracheal lymph nodes.
[mediastinum + G. skopeō, to view]