The diagnosis of malignant pleural mesothelioma has always been a difficult one to make. The initial symptoms of pleural effusion, cough, shortness of breath, do not happen to everyone and are symptoms of other very common diseases. Patients are often treated for pneumonia and then the symptoms persist, and they are then worked up further. Often this takes months from the initial symptoms to diagnosis and sometimes the diagnosis is not made until malignant mesothelioma is advanced. When a patient has respiratory symptoms, imaging, chest x-ray or CT scan, has pleural thickening or an effusion, and a history of asbestos exposure, malignant pleural mesothelioma may be suspected. Since the diagnosis is difficult most major mesothelioma centers reconfirm it with a series of tests. In order to confirm the diagnosis and to stage the disease, usually at a mesothelioma center, one of the tests that a patient undergoes is a cervical mediastinoscopy. This test is usually done if surgery is a treatment option. At a major mesothelioma center of excellence, the diagnosis is confirmed, and the stage of the disease must be identified for the proper treatment options to be presented to the patient and family. If surgery is being considered a procedure that is performed is a cervical mediastinoscopy.
Cervical mediastinoscopy is a procedure that is used to diagnose and stage malignant pleural mesothelioma, to see if the disease is in the lymph nodes of the mediastinum, it is also used for any other diseases in the mediastinum area. The mediastinum is a space between the sternum- often referred to as the breast bone- in the middle of the chest, between the two lungs. The mediastinum consists of lymph nodes, heart and its great vessels, the trachea, the thymus gland. Using a long thin flexible instrument that has a camera attached and a light, the doctor who is doing the procedure can see where he is going, avoid the organs that he needs to, and take a sample of the lymph nodes. Direct visualization allows for a better-quality specimen to lead to a definitive diagnosis.
Cervical mediastinoscopy has been the “gold standard” for staging diseases in the mediastinum. It is a procedure that can be performed with few side effects and complications for most people. Staging of malignant pleural mesothelioma involves testing the lymph nodes in the mediastinum. Staging will tell you the extent of the disease.
A cervical mediastinoscopy is often performed under general anesthesia. The patient usually goes home the same day. An incision is made at the bottom of the patient’s neck so that the doctor can visualize the trachea. The incision is small. The mediastinal area is inspected by the MD visually, next he takes samples of the lymph nodes to check if the disease has spread to them. During the procedure the patient is asleep under general anesthesia due to the sensitive area that the doctor is operating on, and to control any pain that might interfere with the procedure. Once the procedure is complete the skin and muscles are closed with sutures. A small dressing is applied to the area. Post-surgery the patient is usually observed for a few hours for any bleeding or hoarseness and usually discharged that same day.
The procedure, cervical mediastinoscopy is usually well tolerated. With any procedure there are risks that must be discussed with the patient before the surgery. The risks that are most often cited with a cervical mediastinoscopy are bleeding, infection, hoarseness which can indicate temporary or permanent paralysis of the laryngeal nerve. Other complications are a pneumothorax which is air trapped in the space between the lung and the lung lining called the pleural space that can cause the lung to collapse. Air can also become trapped under the skin and cause subcutaneous emphysema, which looks like swelling and is crackly to the touch. Another rare complication is a hole or perforation that can develop in the esophagus, trachea, or large blood vessels in the heart. These are very rare complications, but patients must be told of them while the physician is obtaining Informed Consent for the operation.
In a major mesothelioma center of excellence, they estimate that after the results of the cervical mediastinoscopy the surgical plan changes in up to 25% of the patients.
Cervical mediastinoscopy is usually a low risk operation that yields vital information for the patient and the mesothelioma team. Options for surgery, chemotherapy, radiation therapy, clinical trials are often presented based on the results of this procedure.
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