Cervical mediastinoscopy

Cervical mediastinoscopy is an invasive staging method used for staging 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 scans have a high NPV of 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)
• Contraindications 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)

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 scans have high accuracy in the primary staging of the mediastinum, their accuracy is much lower in the 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 contained less fibrosis.

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