Cervical Mediastinoscopy
Cervical mediastinoscopy is an invasive staging method which is used for staging of the superior and middle mediastinum.
Indications:
-Lymph nodes or masses in the middle mediastinum of unknown origin (sarcoidosis, lymphoma, ...).
-Mediastinal staging in patients with NSCLC.
However, because PET scan has a high NPV up to 93% in primary mediastinal staging in patients with NSCLC cervical mediastinoscopy can nowadays be omitted in some circumstances (peripheral tumor, N0 on PET and CT scan).
Contraindications:
Absolute:
Extreme kyphosis
Cutaneous tracheostomy (after laryngectomy)
Contraindication for general anesthesia
Relative:
Superior vena cava syndrome
previous sternotomy
enlarged goiter
previous radiotherapy
Previous mediastinoscopy
Accessible lymph node stations by cervical mediastinoscopy
Standard (Stations 2R, 2L, 4R,4L,7A)
Extended (stations 5,6)
Stations are not accessible
standard cervical mediastinoscopy
Extended cervical mediastinoscopy
Operative technique
cervical mediastinoscopy is performed under general anesthesia
Complications:
-low-risk procedure
-mortality<0,5% and morbidity<2,5%
-major complication (0,1-0,5%):
-severe hemorrhage (the most important)
On the right side, the azygos vein and the anterior branch of the right pulmonary artery
-injury of the esophagus
-damage to the recurrent laryngeal nerve (usually the left)
-tracheobronchial tree injuries.
Repeat mediastinoscopy
confirmation of downstaging of mediastinal nodes (N2, N3) is a very important prognostic factor after induction therapy
Although PET scan has a high accuracy in primary staging of the mediastinum, its accuracy is much less in restaging of the mediastinum after induction therapy
Technique of repeat mediastinoscopy
Blunt dissection is started on the left side of the trachea. This region was usually not extensively dissected at the previous mediastinoscopy and thus containing less fibrosis.