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Journal of Thoracic Disease Dec 2016The field of diagnostic bronchoscopy has been revolutionized in the last decade primarily with the advent of endobronchial ultrasound (EBUS) but also with the addition... (Review)
Review
The field of diagnostic bronchoscopy has been revolutionized in the last decade primarily with the advent of endobronchial ultrasound (EBUS) but also with the addition of multiple different techniques for "guided-bronchoscopy". These advances have had a substantial impact in the management of lung cancer with bronchoscopy now providing both diagnosis and mediastinal staging in a single procedure. EBUS has, in fact, become the first choice for staging of the mediastinum over cervical mediastinoscopy (CM). Although EBUS is now a well-established technique, there are continuous efforts from the scientific community to improve its diagnostic performance, and these will be reviewed in this manuscript. The term "guided-bronchoscopy" was recently coined to describe a myriad of techniques that guide our bronchoscopes or bronchoscopic tools into the periphery of the lungs in addition to our conventional fluoroscopy. Electromagnetic and non-electromagnetic navigation, thin and ultrathin scopes, as well as radial-probe EBUS have collectively increased our yield for smaller peripheral lung lesions and continue to evolve. Despite this improved diagnostic yield, there is still ample room for improvement and newer techniques are under way. With new therapies available for patients with interstitial lung disease, achieving a specific histologic diagnosis is now of paramount importance. Given the high morbidity and mortality of surgical biopsies, bronchoscopic cryobiopsy is being rapidly adopted as a safer and effective alternative, and it is likely going to play a major role in the management of these diseases in the near future. This manuscript we will focus on recent advances in EBUS, guided-bronchoscopy, and the use of cryobiopsy.
PubMed: 28149581
DOI: 10.21037/jtd.2016.12.70 -
Thorax Jul 1973The indications and techniques for performing the operation of anterior mediastinotomy are described. In the years 1966-71, 116 anterior mediastinotomies were done. The...
The indications and techniques for performing the operation of anterior mediastinotomy are described. In the years 1966-71, 116 anterior mediastinotomies were done. The results of these are presented. In 36 patients the operation was done to provide a histological diagnosis in benign conditions. In 51 patients, with probable carcinoma but normal bronchoscopy, mediastinotomy was done to establish a diagnosis and assess operability; 43 had involved mediastinal nodes proven on histology. In a further 29 patients, with positive bronchoscopic biopsies, mediastinotomy was done to assess operability alone. In all, 14 patients (17·5%) were judged suitable for thoracotomy. Of these, nine had operable disease while five were found to be inoperable. The incidence of complications of the operation was low (11%). These were mostly minor, There were no deaths. Most patients, after anterior mediastinotomy alone, were fit for discharge 48 to 72 hours after the operation. The value of an operation that provides both diagnosis and assessment of mediastinum, lung, and pleura is discussed. The operation of anterior mediastinotomy is compared with mediastinoscopy and, in our opinion, the superiority of the former is demonstrated.
Topics: Biopsy; Bronchial Neoplasms; Bronchoscopy; Humans; Lung Diseases; Lung Neoplasms; Mediastinal Neoplasms; Mediastinum; Methods; Postoperative Complications; Sarcoidosis; Surgical Wound Infection
PubMed: 4741446
DOI: 10.1136/thx.28.4.444 -
Journal of Clinical Oncology : Official... Aug 2023Resectable non-small-cell lung cancer (NSCLC) with a high probability of mediastinal nodal involvement requires mediastinal staging by endosonography and, in the absence... (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE
Resectable non-small-cell lung cancer (NSCLC) with a high probability of mediastinal nodal involvement requires mediastinal staging by endosonography and, in the absence of nodal metastases, confirmatory mediastinoscopy according to current guidelines. However, randomized data regarding immediate lung tumor resection after systematic endosonography versus additional confirmatory mediastinoscopy before resection are lacking.
METHODS
Patients with (suspected) resectable NSCLC and an indication for mediastinal staging after negative systematic endosonography were randomly assigned to immediate lung tumor resection or confirmatory mediastinoscopy followed by tumor resection. The primary outcome in this noninferiority trial (noninferiority margin of 8% that previously showed to not compromise survival, < .0250) was the presence of unforeseen N2 disease after tumor resection with lymph node dissection. Secondary outcomes were 30-day major morbidity and mortality.
RESULTS
Between July 17, 2017, and October 5, 2020, 360 patients were randomly assigned, 178 to immediate lung tumor resection (seven dropouts) and 182 to confirmatory mediastinoscopy first (seven dropouts before and six after mediastinoscopy). Mediastinoscopy detected metastases in 8.0% (14/175; 95% CI, 4.8 to 13.0) of patients. Unforeseen N2 rate after immediate resection (8.8%) was noninferior compared with mediastinoscopy first (7.7%) in both intention-to-treat (Δ, 1.03%; UL 95% CIΔ, 7.2%; = .0144) and per-protocol analyses (Δ, 0.83%; UL 95% CIΔ, 7.3%; = .0157). Major morbidity and 30-day mortality was 12.9% after immediate resection versus 15.4% after mediastinoscopy first ( = .4940).
CONCLUSION
On the basis of our chosen noninferiority margin in the rate of unforeseen N2, confirmatory mediastinoscopy after negative systematic endosonography can be omitted in patients with resectable NSCLC and an indication for mediastinal staging.
Topics: Humans; Lung Neoplasms; Carcinoma, Non-Small-Cell Lung; Mediastinoscopy; Endosonography; Neoplasm Staging; Lymph Nodes
PubMed: 37018653
DOI: 10.1200/JCO.22.01728 -
Turkish Journal of Medical Sciences 2014To analyze patients with Castleman disease who were diagnosed by surgery.
AIM
To analyze patients with Castleman disease who were diagnosed by surgery.
MATERIALS AND METHODS
We retrospectively investigated the postoperative pathological records of operations performed between January 1992 and December 2012 in our hospital. Files of 19 patients with the diagnosis of Castleman disease were analyzed.
RESULTS
There were 13 male and 6 female patients with a mean age of 40.1 + 11.4 (range: 20-57) years. Fifteen thoracotomies and 3 video-assisted thoracoscopies, 12 on the right side and 6 on the left side, and 1 mediastinoscopy were performed. Biopsies and mass excisions were performed in 2 and 17 cases, respectively. Histopathological findings were hyaline vascular-type (n = 16), plasma cellular- type (n = 2), and hyaline vascular plus plasma cellular-type (n = 1) Castleman disease.
CONCLUSION
Castleman disease can occur in all areas of the thorax, but the mediastinum and hilum are the most common locations. Surgical excision is the best method of diagnosis and treatment. Complete excision is curative for local forms of the disease. However, complete excision may not be possible at all times due to local invasion and hypervascularization. Multimodal treatment, including chemotherapy, is recommended in patients with a multicentric form of the disease, and they should be followed closely.
Topics: Adult; Castleman Disease; Female; Humans; Male; Mediastinoscopy; Middle Aged; Retrospective Studies; Thoracic Diseases; Thoracic Surgery, Video-Assisted; Thoracotomy; Tomography, X-Ray Computed; Young Adult
PubMed: 25536724
DOI: 10.3906/sag-1304-38 -
Respirology (Carlton, Vic.) May 2015For a long time lung cancer was associated with a fatalistic approach by healthcare professionals. In recent years, advances in imaging, improved diagnostic techniques... (Review)
Review
For a long time lung cancer was associated with a fatalistic approach by healthcare professionals. In recent years, advances in imaging, improved diagnostic techniques and more effective treatment modalities are reasons for optimism. Accurate lung cancer staging is vitally important because treatment options and prognosis differ significantly by stage. The staging algorithm should include a contrast computed tomography (CT) of the chest and the upper abdomen including adrenals, positron emission tomography/CT for staging the mediastinum and to rule out extrathoracic metastasis in patients considered for surgical resection, endosonography-guided needle sampling procedure replacing mediastinoscopy for near complete mediastinal staging, and brain imaging as clinically indicated. Applicability of evidence-based guidelines for staging of lung cancer depends on the available expertise and level of resources and is directly impacted by financial issues. Considering the diversity of healthcare infrastructure and economic performance of Asian countries, optimal and cost-effective use of staging methods appropriate to the available resources is prudent. The pulmonologist plays a central role in the multidisciplinary approach to lung cancer diagnosis, staging and management. Regional respiratory societies such as the Asian Pacific Society of Respirology should work with national respiratory societies to strive for uniform standards of care. For developing countries, a minimum set of care standards should be formulated. Cost-effective delivery of optimal care for lung cancer patients, including staging within the various healthcare systems, should be encouraged and most importantly, tobacco control implementation should receive an absolute priority status in all countries in Asia.
Topics: Asia; Carcinoma, Non-Small-Cell Lung; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Endosonography; Humans; Lung Neoplasms; Mediastinoscopy; Mediastinum; Neoplasm Staging; Positron-Emission Tomography; Prognosis; Small Cell Lung Carcinoma
PubMed: 25682805
DOI: 10.1111/resp.12489 -
The Thoracic and Cardiovascular Surgeon Jan 2023The coexistence of pleural and pericardial effusions in frail patients with or without confirmed neoplasia necessitates the use of a minimally invasive technique that...
The coexistence of pleural and pericardial effusions in frail patients with or without confirmed neoplasia necessitates the use of a minimally invasive technique that has a minor impact on the patient's general status and allows for fast fluid evacuation and biopsy sampling if necessary. We present a subxiphoid mediastinoscopic autonomous (simultaneous noncommunicating) double fenestration approach for these patients with both diagnostic and therapeutic advantages in selected cases. Using the mediastinoscope alone through the subxiphoid incision can considerably reduce the duration of operation, allow for fluid evacuation, and significantly alleviate the patient's symptoms. This method enables the sampling of pleural and pericardial fluids and targeted tissue, if necessary.
Topics: Humans; Mediastinoscopes; Treatment Outcome; Pericardial Effusion; Mediastinoscopy; Biopsy
PubMed: 36216329
DOI: 10.1055/s-0042-1757177 -
Canadian Respiratory Journal 2014Staging of the mediastinal and hilar lymph nodes plays a crucial role in identifying the best treatment option for patients with confirmed or suspected lung cancer and,... (Review)
Review
Staging of the mediastinal and hilar lymph nodes plays a crucial role in identifying the best treatment option for patients with confirmed or suspected lung cancer and, in many cases, can simultaneously confirm a diagnosis of cancer. Noninvasive modalities, such as computed tomography (CT), positron emission tomography (PET) and PET-CT, are an important first step in this assessment. Ultimately, invasive staging is frequently required to confirm or rule out the presence of metastatic disease within the lymph nodes. The present focused review describes and compares noninvasive and invasive modalities for mediastinal staging in lung cancer.
Topics: Endoscopic Ultrasound-Guided Fine Needle Aspiration; Humans; Lung Neoplasms; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Mediastinoscopy; Mediastinum; Neoplasm Staging; Positron-Emission Tomography; Tomography, X-Ray Computed
PubMed: 24914606
DOI: 10.1155/2014/890108 -
British Medical Journal May 1965
Topics: Biopsy; Endoscopy; Humans; Mediastinoscopy; Mediastinum; Neoplasms; Thoracic Neoplasms
PubMed: 14273524
DOI: 10.1136/bmj.1.5443.1167 -
Journal of Thoracic Oncology : Official... Apr 2007Indications for remediastinoscopy include recurrent and second primary lung cancer, an inadequate first procedure, lung cancer occurring after an unrelated disease such... (Review)
Review
Indications for remediastinoscopy include recurrent and second primary lung cancer, an inadequate first procedure, lung cancer occurring after an unrelated disease such as lymphoma, and restaging after induction therapy. Nowadays, restaging is the most frequent indication for remediastinoscopy. Only patients with proven mediastinal downstaging will benefit from a subsequent surgical resection. In contrast to imaging or functional studies, remediastinoscopy provides pathologic evidence of response after induction therapy. Although technically more challenging than a first procedure, remediastinoscopy can select patients for subsequent thoracotomy and provides prognostic information. In most recent series, sensitivity of remediastinoscopy is higher than 70% with an accuracy of approximately 85%. Survival also depends on the findings at remediastinoscopy, with patients with persisting mediastinal involvement having a poor prognosis. An alternative approach consists of the use of minimally invasive staging procedures as endobronchial or endoscopic esophageal ultrasonography to obtain initial proof of mediastinal nodal involvement. Mediastinoscopy is subsequently performed after induction therapy to evaluate response. In this way, a technically more difficult remediastinoscopy can be avoided.
Topics: Carcinoma, Non-Small-Cell Lung; Female; Humans; Lung Neoplasms; Male; Mediastinoscopy; Neoplasm Recurrence, Local; Neoplasm Staging; Remission Induction; Sensitivity and Specificity; Survival Analysis
PubMed: 17409813
DOI: 10.1097/01.JTO.0000263724.07439.ff