THE ROLE OF MEDIASTINOSCOPY IN THE DIAGNOSIS OF RESPIRATORY DISEASES

Öz

Objective:  Cervical mediastinoscopy  (CMDx) has long been considered the gold standard for mediastinal lymph node evaluation and lung cancer staging. Despite the advent of minimally invasive techniques such as endobronchial ultrasound-guided transbronchial needle aspiration  (EBUS-TBNA) and PET/CT, CMDx remains essential in clinical environments where advanced equipment is limited. This study aimed to evaluate the safety, diagnostic efficacy, and clinical role of conventional CMDx.
Material and Methods: A retrospective single-center analysis was conducted on 121 patients who underwent CMDx between July 2012 and May 2019. Indications included lung cancer staging  (58 patients, 47.9%) and diagnostic evaluation of mediastinal lymphadenopathy  (63 patients, 52.1%). Patient demographics, nodal stations biopsied, pathological outcomes, and perioperative complications were reviewed.
Results: Among lung cancer patients, malignant pathology was confirmed in 28 cases  (48.2%), while benign findings were reported in 30 cases  (51.8%). CMDx provided definitive diagnoses in 13.8% of patients with previously inconclusive results. In the lymphadenopathy group, sarcoidosis  (31.7%) and tuberculosis  (27.0%) were the most common diagnoses. CMDx effectively distinguished granulomatous diseases from malignancies. Complications were rare: one major event  (pulmonary artery rupture, 0.8%) required sternotomy, and one minor case of transient hoarseness was reported. No procedure-related mortality occurred.
Conclusion: Conventional CMDx remains a safe, effective, and indispensable tool for mediastinal tissue diagnosis and lung cancer staging. It provides critical histopathological confirmation, particularly in regions with high prevalence of granulomatous diseases and limited access to advanced endoscopic modalities.

Anahtar Kelimeler

• Mediastinoscopy
• Lung Neoplasm
• Lymphadenopathy
• Sarcoidosis
• Tuberculosis

Etik Beyan

The study protocol was approved by Yozgat Bozok University Ethics Committee (2017.KAEK 189.2022.08.25.06).

Teşekkür

The authors declared that this study has received no financial support and no conflict of interest between the authors.

Göğüs Hastalıklarının Teşhis Edilmesinde Mediastinoskopinin Yeri

Öz

Amaç: Servikal mediastinoskopi  (CMDx), mediastinal lenf nodu değerlendirmesi ve akciğer kanseri evrelemesinde uzun süredir altın standart kabul edilmektedir. Endobronşiyal ultrason  (EBUS-TBNA) ve PET/BT gibi minimal invaziv yöntemlerin gelişmesine rağmen, ileri donanımın sınırlı olduğu klinik ortamlarda CMDx hâlâ kritik öneme sahiptir. Bu çalışma, konvansiyonel CMDx’in güvenliğini, tanısal etkinliğini ve klinik rolünü değerlendirmeyi amaçlamaktadır.
Gereç ve Yöntemler: Temmuz 2012 – Mayıs 2019 tarihleri arasında CMDx uygulanan 121 hasta retrospektif olarak incelendi. Endikasyonlar akciğer kanseri evrelemesi  (58 hasta, %47,9) ve mediastinal lenfadenopati tanısı  (63 hasta, %52,1) idi. Demografik veriler, biyopsi alınan lenf nodu istasyonları, patolojik sonuçlar ve perioperatif komplikasyonlar değerlendirildi.
Bulgular:  Akciğer kanseri grubunda 28 hastada  (%48,2) malign, 30 hastada  (%51,8) benign patoloji saptandı. Önceki girişimlerle tanı konulamayan 8 hasta  (%13,8) CMDx ile tanı aldı. Lenfadenopati grubunda en sık tanılar sarkoidoz  (%31,7) ve tüberküloz  (%27,0) idi. CMDx granülomatöz hastalıkları malignitelerden ayırmada etkili oldu. Komplikasyon oranı düşüktü: bir majör olay  (pulmoner arter rüptürü, %0,8) sternotomi ile tedavi edildi; bir minör olay geçici ses kısıklığıydı. İşleme bağlı mortalite görülmedi.
Sonuç: Konvansiyonel CMDx, akciğer kanseri ve mediastinal lenfadenopati tanı ve evrelemesinde güvenli, etkili ve vazgeçilmez bir yöntemdir. Özellikle granülomatöz hastalıkların sık görüldüğü bölgelerde ve ileri endoskopik yöntemlere erişimin sınırlı olduğu kliniklerde histopatolojik doğrulama için kritik rol oynamaktadır.

Anahtar Kelimeler

• Mediastinoskopi
• Akciğer Kanseri
• Lenfadenopati
• Sarkoidoz
• Tüberküloz

Etik Beyan

The study protocol was approved by Yozgat Bozok University Ethics Committee (2017.KAEK 189.2022.08.25.06).

Teşekkür

Yazarlar, bu çalışmanın herhangi bir finansal destek almadığını ve yazarlar arasında herhangi bir çıkar çatışması bulunmadığını beyan etmişlerdir.

Kaynakça

1. Carlens E. Mediastinoscopy: a method for inspection and tissue biopsy in the superior mediastinum. Dis Chest. 1959;36:343-52.
2. Gupta N, Muthu V, Agarwal R, Dhooria S. Role of EBUS-TBNA in the Diagnosis of Tuberculosis and Sarcoidosis. J Cytol. 2019;36 (2):128-30.
3. Iyer H, Anand A, Sryma PB, Gupta K, Naranje P, Damle N, et al. Mediastinal lymphadenopathy: a practical approach. Expert Rev Respir Med. 2021;15 (10):1317-34.
4. Islam S, Walker RC. Advanced imaging (positron emission tomography and magnetic resonance imaging) and image-guided biopsy in initial staging and monitoring of therapy of lung cancer. Cancer J. 2013;19 (3):208-16.
5. Zhang R, Ma Y, Xu G, Gao X, Luo G, Lin Q, et al. Endobronchial ultrasound-guided transbronchial needle aspiration and cervical mediastinoscopy for mediastinal staging of non-small cell lung cancer: a retrospective comparison study. J Thorac Dis. 2018;10 (3):1951-9.
6. Lemaire A, Nikolic I, Petersen T, Haney JC, Toloza EM, Harpole DH, Jr., et al. Nine-year single center experience with cervical mediastinoscopy: complications and false negative rate. Ann Thorac Surg. 2006;82 (4):1185-9; discussion 9-90.
7. Dunning J, Walker WS. Troublesome bleeding at mediastinoscopy. Ann Cardiothorac Surg. 2012;1 (1):111-2. Detterbeck FC, Boffa DJ, Kim AW, Tanoue LT. The Eighth Edition Lung Cancer Stage Classification. Chest. 2017;151 (1):193-203.
8. Bolliger M, Kroehnert JA, Molineus F, Kandioler D, Schindl M, Riss P. Experiences with the standardized classification of surgical complications (Clavien-Dindo) in general surgery patients. Eur Surg. 2018;50 (6):256-61.

9. Fournier C, Hermant C, Gounant V, Escarguel B, Thibout Y, Lachkar S, et al. Diagnostic of mediastinal lymphadenopathy in extrathoracic cancer: A place for EBUS-TBNA in real life practice? Respir Med Res. 2019;75:1-4.
10. Wei B, Bryant AS, Minnich DJ, Cerfolio RJ. The safety and efficacy of mediastinoscopy when performed by general thoracic surgeons. Ann Thorac Surg. 2014;97 (6):1878-83; discussion 83-4.
11. Passlick B. Initial surgical staging of lung cancer. Lung Cancer. 2003;42 (2):21-5.
12. Farsad M. FDG PET/CT in the Staging of Lung Cancer. Curr Radiopharm. 2020;13 (3):195-203.
13. Gao SJ, Kim AW, Puchalski JT, Bramley K, Detterbeck FC, Boffa DJ, et al. Indications for invasive mediastinal staging in patients with early non-small cell lung cancer staged with PET-CT. Lung Cancer. 2017;109:36-41.
14. Akaike G, Itani M, Shah H, Ahuja J, Yilmaz Gunes B, Assaker R, et al. PET/CT in the Diagnosis and Workup of Sarcoidosis: Focus on Atypical Manifestations. Radiographics. 2018;38 (5):1536-49.
15. El-Galaly TC, Villa D, Gormsen LC, Baech J, Lo A, Cheah CY. FDG-PET/CT in the management of lymphomas: current status and future directions. J Intern Med. 2018;284 (4):358-76.
16. Sanchez-Lorente D, Guzman R, Boada M, Guirao A, Carriel N, Molins L. N2 disease in non-small-cell lung cancer: straight to surgery? Future Oncol. 2018;14 (6s):13-6.
17. Yun JK, Bok JS, Lee GD, Kim HR, Kim YH, Kim DK, et al. Long-term outcomes of upfront surgery in patients with resectable pathological N2 non-small-cell lung cancer. Eur J Cardiothorac Surg. 2020;58 (1):59-69.
18. Isgorucu O, Citak N, Acikmese B, Akalin Fener N, Buyukkale S, Sayar A. Comparative evaluation of staging algorithms proven N2 non-small cell lung cancer treated by lung resection after neoadjuvant therapy. Turk Gogus Kalp Damar Cerrahisi Derg. 2022;30 (3):372-80.
19. Baughman RP, Iannuzzi MC. Diagnosis of sarcoidosis: when is a peek good enough? Chest. 2000;117 (4):931-2. Kim HR, Hwang SS, Ro YK, Jeon CH, Ha DY, Park SJ, et al. Solid-organ malignancy as a risk factor for tuberculosis. Respirology. 2008;13 (3):413-9.
20. Erer OF, Erol S, Anar C, Aydogdu Z, Ozkan SA. Diagnostic yield of EBUS-TBNA for lymphoma and review of the literature. Endosc Ultrasound. 2017;6 (5):317-22.
21. Park BJ, Flores R, Downey RJ, Bains MS, Rusch VW. Management of major hemorrhage during mediastinoscopy. J Thorac Cardiovasc Surg. 2003;126 (3):726-31.