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Der Chirurg; Zeitschrift Fur Alle... Jan 2008Thymomas, lymphomas, and germ cell tumors are the most frequent lesions of the anterior mediastinum, whereas endodermal (bronchogenic) cysts and lymphomas are the most... (Comparative Study)
Comparative Study Review
Thymomas, lymphomas, and germ cell tumors are the most frequent lesions of the anterior mediastinum, whereas endodermal (bronchogenic) cysts and lymphomas are the most frequent lesions of the middle mediastinum. In the posterior mediastinum, neurogenic tumors and soft-tissue sarcomas are the most frequent. Depending on tumor location, mediastinoscopy, mediastinotomy, and thoracoscopy are the preferred diagnostic methods. Surgical treatment of thymoma is the gold standard, and median sternotomy is the most frequently applied approach. The decisive prognostic and therapeutic criteria are Masaoka staging, WHO classification, and R0 status. Thoracoscopy should be performed only in patients with myasthenia gravis and with very small tumors. Surgical treatment is highly recommended in patients with locally recurrent tumors. The importance of surgical treatment of germ cell tumors is determined by a negative concentration of beta-HCG and alpha-fetoprotein and in cases of residual tumor after chemotherapy. Bronchogenic cysts always require resection because of their high complication rate (66%) after conservative treatment. In these cases complete resection is necessary due to the probability of recurrence. Ninety-eight percent of neurogenic tumors in adults are benign and usually resected via thoracoscopy or thoracotomy, depending on location and size.
Topics: Adult; Age Factors; Child; Female; Humans; Incidence; Lymphoma; Male; Mediastinal Neoplasms; Mediastinoscopy; Mediastinum; Neoplasm Staging; Neoplasms, Germ Cell and Embryonal; Prognosis; Radiography; Thoracoscopy; Thoracotomy; Thymoma; Thymus Neoplasms
PubMed: 18058077
DOI: 10.1007/s00104-007-1438-x -
Minerva Medica Aug 2007Diagnosis of indeterminate mediastinal masses and staging of lung cancer poses a significant challenge. Options for tissue diagnoses include computed tomography... (Review)
Review
Diagnosis of indeterminate mediastinal masses and staging of lung cancer poses a significant challenge. Options for tissue diagnoses include computed tomography (CT)-guided percutaneous biopsy, transbronchial fine-needle aspiration, mediastinoscopy/mediastinotomy or thoracoscopy, but these investigations have limitations in terms of tissue yield, safety profile and cost. Trans-esophageal endoscopic ultrasound scanning (EUS) is a new minimal invasive method that provides high resolution imaging of the mediastinum using high frequency ultrasound probes attached to the tip of a flexible endoscope and offers in addition the facility of fine needle aspiration (EUS-FNA) or tru-cut biopsy (TCB) under real-time ultrasound guidance. EUS-FNA allows access to the posterior mediastinum and tissue acquisition under real-time ultrasound guidance through the oesophageal wall. Indications of EUS-FNA in the mediastinum is to obtain a diagnosis from an unknown primary lesion or to sample tissue from mediastinal lymph nodes in order to stage lung cancer or to diagnose other diseases involving lymph nodes of the mediastinum eg. TB, Sarcoidosis, histoplasmosis or metastases from a vide range of cancers. If lymphoma is suspected EUS-TCB of an enlarged mediastinal lymph node is preferred. EUS- FNA is safe, can be done on an outpatient basis, is well tolerated and provides an excellent diagnostic yield with a sensitivity of more than 90% and a specificity of 100%. Compared to CT, PET, mediastinoscopy as well as transbronchial aspiration, EUS-FNA is found to be significant more accurate for staging of non-small cell lung cancer. However, mediastinoscopy is at present still regarded as the gold standard in the region of the anterior mediastinum since EUS can not image this region due to the air-filled trachea. Recently, endobronchial ultrasound guided transbronchial needle aspiration Biopsy (EBUS-TBNA) has been developed and several publications have now documented high diagnostic values with sensitivities of more than 90% in the staging of NSCLC. A recent publication from our group has documented a sensitivity and specificity of 100% when EUS-FNA and EBUS-TBNA is used in combination for staging of the mediastinum. It seems therefore logical to assume that the combination of EUS-FNA and EBUS-TBNA will replace more invasive methods such as mediastinoscopy for diagnosis and staging of lung cancers in the near future.
Topics: Biopsy, Fine-Needle; Endosonography; Humans; Lung Neoplasms; Mediastinal Neoplasms; Mediastinoscopy; Mediastinum; Neoplasm Staging; Positron-Emission Tomography; Sensitivity and Specificity; Tomography, X-Ray Computed; Ultrasonography, Interventional
PubMed: 17921946
DOI: No ID Found -
Interactive Cardiovascular and Thoracic... Sep 2003The various techniques used to perform biopsies of mediastinal masses--mediastinoscopy, mediastinotomy, extended cervical mediastinoscopy, and assisted...
The various techniques used to perform biopsies of mediastinal masses--mediastinoscopy, mediastinotomy, extended cervical mediastinoscopy, and assisted video-thoracoscopy--have already been amply described. In this study the authors give particular attention to ultrasonically guided percutaneous biopsy. Between January 1998 and July 2001 42 patients underwent anterior mediastinal core needle biopsy with ultrasonic guidance. An accurate diagnosis was made for all the patients, with a sensitivity and specificity of 100%. Two cases of pneumothorax were seen, with pleural drainage and a 5-day hospitalization necessary in one of the cases. The remaining 40 patients were treated as outpatients and were discharged within 4 h of the procedure. Ultrasonically guided percutaneous core-needle biopsy is a safe procedure for the diagnosis of the anterior mediastinal masses.
PubMed: 17670057
DOI: 10.1016/S1569-9293(03)00068-9 -
Annals of the Royal College of Surgeons... May 2007
Topics: Biopsy; Humans; Mediastinal Neoplasms; Thoracic Surgery, Video-Assisted
PubMed: 17539188
DOI: 10.1308/rcsann.2007.89.4.435 -
Chinese Medical Journal Apr 2007Anterior mediastinal masses include a wide variety of diseases from benign lesions to extremely malignant tumors. Management strategies are highly diverse and depend...
BACKGROUND
Anterior mediastinal masses include a wide variety of diseases from benign lesions to extremely malignant tumors. Management strategies are highly diverse and depend strongly on the histological diagnosis as well as the extent of the disease. We reported a prospective study comparing the usefulness of core needle biopsy and mini-mediastinotomy under local anesthesia for histological diagnosis in anterior mediastinal masses.
METHODS
A total of 40 patients with masses of unknown histology and located either at or near the anterior mediastinum received biopsy prior to treatment. The diagnostic methods were core needle biopsy in 28 patients and biopsy through mini-mediastinotomy under local anesthesia in 15 patients (including 3 patients for whom core needle biopsy failed to yield a definite diagnosis).
RESULTS
Histological diagnosis was achieved in 18 of the 28 patients receiving core needle biopsy. Of them, all 4 patients with pleural fibromas and 9 of the 12 patients (75%) with pulmonary mass were diagnosed definitively. In the remaining 12 patients with mediastinal mass, histological diagnosis was achieved in only 5 patients (41.7%). In contrast, biopsy through a mini-mediastinotomy failed in only 3 patients. In the remaining 12 patients with huge mediastinal masses, who underwent mini-mediastinotomy, a definitive histological diagnosis was reached by pathological and/or immunohistochemical study (diagnostic yield 85.7% in 12 of 14 cases of mediastinal mass, P = 0.038 vs core needle biopsy). For the 9 patients with thymic epithelial tumors, the diagnostic yield was 40% (2 in 5 cases) for core needle biopsy and 83.3% (5 in 6 cases) for mini-mediastinotomy. There was no morbidity in patients receiving mini-mediastinotomy. In the 30 patients with biopsy-proven histological diagnosis, the results contributed to therapeutic decision making in 25 cases (83.3%).
CONCLUSIONS
Core needle biopsy is effective in the diagnosis of pulmonary and pleural diseases. Yet its diagnostic yield in mediastinal mass is rather low. Superior to core needle biopsy, biopsy through a mini-mediastinotomy under local anesthesia is highly effective in the histological diagnosis of anterior mediastinal mass, and has a satisfactory diagnostic yield. The method is safe, minimally invasive, cost-effective, and useful in therapeutic decision making for anterior mediastinal masses.
Topics: Adult; Biopsy, Needle; Female; Humans; Male; Mediastinal Diseases; Mediastinum; Minimally Invasive Surgical Procedures; Prospective Studies; Reproducibility of Results; Sensitivity and Specificity
PubMed: 17517183
DOI: No ID Found -
The Annals of Thoracic Surgery Dec 2006Accurate staging of patients with lung cancer is imperative in generating an appropriate treatment strategy. This study examined the clinical performance of anterior...
BACKGROUND
Accurate staging of patients with lung cancer is imperative in generating an appropriate treatment strategy. This study examined the clinical performance of anterior mediastinotomy in staging patients with suspected left upper lobe non-small cell lung cancer.
METHODS
This study was designed as a retrospective cohort. All patients with suspected left upper lobe cancer and otherwise normal computed tomography scan results were eligible. Patients with clinically unresectable disease (advanced disease or not fit for surgery) were excluded. After exclusions, 151 patients were stratified into two groups: 117 patients had cervical and anterior mediastinotomy as part of preoperative staging, and 34 had cervical mediastinoscopy only. The primary outcome was rate of preventable thoracotomy defined as thoracotomy during which either metastases to aortopulmonary or paraaortic lymph nodes, or mediastinal invasion was identified.
RESULTS
The rate of preventable thoracotomy for the anterior mediastinotomy arm was 4 (3.4%) of 117, compared with 1 (2.9%) of 34 for cervical mediastinoscopy-only arm (p = 0.99). The rate of morbidity in the anterior mediastinotomy arm was 8 (6.8%) of 117, compared with 2 (5.8%) of 34 for the cervical mediastinoscopy-only arm (p = 0.99). Anterior mediastinotomy patients stayed in hospital 1 day longer (p = 0.008). Anterior mediastinotomy was successful at harvesting one or more lymph nodes in 67% of patients. Five patients (4.3%) who underwent anterior mediastinotomy were spared a thoracotomy by identification of metastases to aortopulmonary lymph nodes.
CONCLUSIONS
In patients with suspected left upper lobe lung cancer and otherwise normal computed tomography scan results, anterior mediastinotomy does not significantly reduce the rate of preventable thoracotomy.
Topics: Aged; Carcinoma, Non-Small-Cell Lung; Female; Humans; Lung Neoplasms; Male; Mediastinum; Middle Aged; Neoplasm Staging; Retrospective Studies; Thoracotomy
PubMed: 17126099
DOI: 10.1016/j.athoracsur.2006.06.031 -
Respiration; International Review of... 2006Surgical techniques remain central to the diagnosis and staging of lung cancer. Clinical situations which invoke the role of surgery include the diagnosis of solitary... (Review)
Review
Surgical techniques remain central to the diagnosis and staging of lung cancer. Clinical situations which invoke the role of surgery include the diagnosis of solitary pulmonary masses, staging of the mediastinum, restaging of the mediastinum and the assessment of resectability. The techniques available include cervical mediastinoscopy, anterior mediastinotomy, video-assisted thoracoscopy and different procedures for intra-operative mediastinal lymph node assessment including systematic nodal dissection, lobe-specific nodal dissection and sentinel node mapping. The staging of lung cancer is continuously evolving as technological advances combine with clinical advances to better stratify patients into treatment and prognostic categories and alter pre-operative investigation algorithms. Although most of the surgical techniques have been around for many years, it is their application in future which is likely to change. The increasing use of positron emission tomography/computed tomography fusion imaging is raising the proportion of patients being shown to have additional lesions that could contraindicate surgical treatment but which require tissue confirmation to exclude a false-positive examination. Many such lesions are amenable to the expanding techniques available to the interventional endoscopist. The relationship between the surgeon and the endoscopist must become closer to ensure that the appropriate technique is used at each point in the patient's pathway. The future of surgical techniques will be driven by: (1) developments in screening and imaging, with a likelihood that more early stage cancers will present and may be amenable to minimally invasive surgical approaches with the possibility of a role for robotics and nanotechnology; (2) improvements in neoadjuvant therapies which will demand flawless mediastinal staging and restaging; (3) advances in molecular biology which, whilst currently requiring that surgery provide samples of tumour and lymph node tissue to fully characterize the disease, do hold the promise that ever smaller amounts of tissue will be required and that eventually the genetic fingerprint will provide a biological ultrastaging to perhaps supersede anatomical staging.
Topics: Humans; Lung Neoplasms; Mediastinoscopy; Neoplasm Staging; Thoracic Surgery, Video-Assisted
PubMed: 17119351
DOI: 10.1159/000095901 -
Tuberkuloz Ve Toraks 2006Mediastinal tumors and cysts are relatively uncommon lesions requiring histologic confirmation. This retrospective study reports the experience of our department in the...
Mediastinal tumors and cysts are relatively uncommon lesions requiring histologic confirmation. This retrospective study reports the experience of our department in the diagnosis and treatment of mediastinal lesions. Mediastinal lesions that were surgically treated in 200 patients aged 6-84 years, during a period of 28 years, were included in this series. Sixty patients had an apparently non-resectable lesion or lymphadenopathy of the anterior superior mediastinum. They had an anterior mediastinotomy and biopsy of the mediastinal lesion. No perioperative deaths were recorded in those patients. There were recorded 5 (8.3%) complications. Histological diagnosis was established in all patients: lymphoma (n = 21), metastatic carcinoma (n = 16), thymic lesions (n = 10), germ cell tumor (n = 3), other lesions (n = 10). The remainder 140 patients underwent a resection of the mediastinal lesion. One (0.7%) perioperative death and 21 (15%) complications were recorded. The histological diagnosis of the excised lesions was: thymic lesions (n = 60), neural tumors (n = 21), thyroid lesions (n = 14), bronchial cysts (n = 12), pericardial cysts (n = 10), germ cell tumors (n = 6), other lesions (n = 17). Our results are compared favorably with those reported in international literature. Surgery is the management of choice for patients with mediastinal lesions. It allows for establishing certain histological diagnosis and curative excision of the lesion, when it is necessary, with low operative risk.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Bronchogenic Cyst; Child; Female; Humans; Male; Mediastinal Cyst; Mediastinal Diseases; Mediastinal Neoplasms; Medical Records; Middle Aged; Outcome Assessment, Health Care; Radiography; Retrospective Studies; Thoracic Surgical Procedures; Thymus Neoplasms; Turkey
PubMed: 17001536
DOI: No ID Found -
The Annals of Thoracic Surgery Aug 2006Surgery for retrosternal goiter is uncommon. Most of the benign retrosternal goiters can be delivered and resected through a standard cervical incision. However, there...
Surgery for retrosternal goiter is uncommon. Most of the benign retrosternal goiters can be delivered and resected through a standard cervical incision. However, there are cases in which resection of the retrosternal goiter requires additional thoracic access to the standard transverse cervical incision in the form of partial or complete median sternotomy or even a thoracotomy. We propose and describe a novel technique of combining anterior mediastinotomy to the cervical incision as an adjunct to facilitate delivering the difficult retrosternal goiter by bi-manual manipulation. This technique avoids the trauma and postoperative morbidity of a median sternotomy or thoracotomy and proves effective in solving the technical, functional, financial, and aesthetic problems.
Topics: Aged; Aged, 80 and over; Female; Goiter; Humans; Mediastinum; Sternum; Thyroidectomy
PubMed: 16863815
DOI: 10.1016/j.athoracsur.2005.07.097 -
La Radiologia Medica Apr 2006The mediastinum is divided into compartments (anterior, middle, posterior) on the basis of lateral chest radiographs. Several anatomical and radiological classifications...
The mediastinum is divided into compartments (anterior, middle, posterior) on the basis of lateral chest radiographs. Several anatomical and radiological classifications of the mediastinum are reported in the literature. Most mediastinal abnormalities are initially suspected following chest radiography; the need for further investigation and the most appropriate imaging modality are largely dictated by the tentative diagnosis made on this examination. Although routine chest radiography initiates the evaluation of mediastinal disorders, it is rarely diagnostic: notable exceptions are teeth or bones within a mass, which are diagnostic of a teratoma; air/fluid levels suggest an oesophageal origin, hernia, cyst, or abscess. Chest radiography is followed by spiral computed tomography (sCT). However, even sCT with contrast material is occasionally diagnostic (a confident diagnosis can be made of some lesions such as mature teratoma and mediastinal goiter) but is usually sufficient for preoperative evaluation before mediastinotomy or mediastinoscopy: it is instrumental in planning further diagnostic workup. In certain cases, magnetic resonance imaging (MRI) may be complementary to sCT, but its use is not considered routine. Besides, although the anterior mediastinum is suitable for sonographic examination, the diagnostic value of ultrasonography has not been fully exploited. Thyroid scanning with radioactive iodine is useful in identifying and evaluating masses of suspected thyroid origin. The role of fluorodeoxyglucose positron emission tomography (FDG-PET) in mediastinal diseases continues to be evaluated: it has potential for differentiating between benign and malignant disease and is expected to play a more extensive role in the imaging of mediastinal neoplasms in the future. In this paper, the radiological features of masses located in the anterior mediastinum are discussed, with particular reference to radiographic and CT patterns useful to the clinician's everyday practice.
Topics: Contrast Media; Diagnostic Imaging; Fluorodeoxyglucose F18; Goiter; Humans; Magnetic Resonance Imaging; Mediastinal Diseases; Mediastinal Neoplasms; Mediastinoscopy; Mediastinum; Positron-Emission Tomography; Radiography, Thoracic; Radiopharmaceuticals; Teratoma; Tomography, Spiral Computed; Ultrasonography
PubMed: 16683080
DOI: 10.1007/s11547-006-0031-6